NHS FORTH VALLEY. Guidance on Alcohol Dependence: Hospital Management of Alcohol Withdrawal (Emergency Department and in-patient setting)

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1 NHS FORTH VALLEY Guidance on Alcohol Dependence: Hospital Management of Alcohol Withdrawal (Emergency Department and in-patient setting) Approved 09/04/2015 Version 4.2 Date of First Issue July 2002 Review Date 31/10/2016 Current Issue Date 09/04/2015 EQIA Yes 07/10/2014 Author / Contact Contacts: Sue Gilfillan, Dr Michael Gotz, Dr Claire McIntosh, Group / Committee Final Approval Area Drug & Therapeutic Committee This document can, on request, be made available in alternative formats NHS Forth Valley Version 4.2 April 2015 page 1 of 25

2 Consultation and Change Record Contributing Authors: Jennifer Berry, Charge Nurse Hospital Addiction Team Dr Pete Bramley, Consultant Hepatologist/Gastroenterologist Dr David Cumming, Consultant Psychiatrist Susan Gilfillan, Charge Nurse - Hospital Addiction Team Dr Timothy Gordon-Walker, Consultant Gastroenterologist Dr Michael Gotz, Consultant Psychiatrist Dr Keith Jacques, Emergency Department Consultant Jean Logan, Lead Pharmacist MH & SM Dr Claire McIntosh, Consultant Psychiatrist Dr Elizabeth Miller, Consultant in Ageing Health Consultation Process: Barry Sharp, Charge Nurse, Ward 2, FVRH The group wish to acknowledge the work of NHS Lanarkshire, Tayside, Greater Glasgow & Clyde and Inverness in the development of symptom triggered scoring and dosing schedules of benzodiazepines for the alcohol withdrawal chart. Substance Misuse Clinical Governance Prescribing Subgroup Primary Care Drug & Therapeutics Committee Acute Drug & Therapeutics Committee Area Drug & Therapeutics Committee Distribution: NHS Forth Valley Intranet/ Internet Change Record Date Author Change Version July 2002 Sept 2007 JL/CB JL/CB March 2009 JL/CM 2.1 November 2012 VK/SG Reformat in guideline template. Revised guidance, including FAST and SMAST-G screening tools and symptom triggered dosing of chlordiazepoxide Version 4.2 April 2015 page 2 of 25 3

3 December 2012 VK (request by ADTC) P5: FAST should be utilised for screening all adult patients under 65 years old, except women who are pregnant Appendix 5: Prophylactic Pabrinex dose circle appropriate route IV/IM added 3 March 2013 VK/SG Details of clinic for ABI referral added to section 3.1, appendices 1 and 3 3 Aug 2014 JL/SG P2: acknowledgement to NHS Boards 4 P5: bullet on MH screening questions added P7: amended HAT contact numbers P10: patient information link changed to NHS Inform P12: amended section 7 to include refractory AWD P13: useful contacts box added P14: references refreshed P15 &18: score chart actions amended P22: care bundle audit added Oct 2014 SG Appendix 5 & 6 minor amendments 4.1 March 2015 SG/JL Appendices 1, 4 and 5 amendments 4.2 P7: text to reflect amendments to Appendix 1 P10: Add CAUTION box in Section 5.1 Version 4.2 April 2015 page 3 of 25

4 1. Introduction 2. Scope 3. Screening and Assessment 3.1 Patients who do not require pharmacological management of alcohol withdrawal 4. Recognition of Wernicke s Korsakoff Syndrome 4.1 Management of Patients With or at Risk of Wernicke s Encephalopathy 5. Replacement of Alcohol with an Alternative CNS Depressant 5.1 Symptom Triggered Dosing of Chlordiazepoxide for Alcohol Withdrawal 6. Management of Disturbed Patients and those with Complex Needs 7. Management of Older People with Complex Needs 8. Monitoring 9. Discharge Planning 9.1 Pharmacological Interventions 9.2 Psychological and Social help 10. References and Internet/Intranet Links Appendices 1. Fast Alcohol Screening Test (FAST) Patient Score Chart 2. Antenatal Alcohol Screening Test 3. Short Michigan Alcoholism Screening Test Geriatric Version (SMAST-G) 4. Hospital Management of Alcohol Withdrawal Guidance Flowchart 5. Hospital Management of Alcohol Withdrawal Schedule 6. Management of Wernicke s Encephalopathy Guidance Flowchart 7. Alcohol Withdrawal Care Bundle Version 4.2 April 2015 page 4 of 25

5 1. Introduction In alcohol-dependent drinkers withdrawal symptoms can start from 6 to 24 hours after the last alcoholic drink and usually last 5 7 days, occasionally longer. Early symptoms include tremor, sweating, anorexia, nausea, insomnia and anxiety. It is vital to detect symptoms early; having a high level of suspicion and taking a comprehensive history helps. Between 10 and 60 hours from cessation, withdrawal seizures are a risk. They may precede or accompany life threatening delirium tremens, which may develop after 72 hours if withdrawal symptoms persist. Predisposing factors include hypoglycaemia, hypokalaemia, hypomagnesaemia or hypocalcaemia. Where possible, patients should be managed in an environment with adequate lighting, cool ambient temperature, good ventilation and supportive nursing care. This guideline is part of a suite of documents which aim to ensure NHS Forth Valley provides safe, effective and person centred care and services for people who misuse alcohol. This guideline links to other relevant guidance below: Alcohol dependence: screening and identification (in development) Alcohol dependence: community management of alcohol withdrawal Alcohol dependence: maintenance of abstinence 2. Scope This guidance applies to all in-patient areas within NHS Forth Valley and the Accident and Emergency Department, and covers the management of adult and elderly patients. Senior medical staff must be consulted in the management of patients aged 17 years or younger. Specialist advice must be sought on the management of pregnant women requiring treatment for alcohol withdrawal. The risks and benefits should be considered on a case by case basis. 3. Screening and Assessment The appropriate alcohol screening test should be used: The Fast Alcohol Screening Test (FAST) should be utilised for screening all adult patients under 65 years old, except women who are pregnant (Appendix 1). In the Mental Health Unit (Wards 1-5 FVRH) refer to the screening questions in the assessment documentation. The Antenatal Alcohol Screening Test should be used in pregnant ladies (Appendix 2). In patients aged 65 and over, the Short Michigan Alcoholism Screening Test Geriatric Version (SMAST-G) should be used (Appendix 3). In addition, it is also critical to take an alcohol history to supplement information obtained from the screening process. This should include history of alcohol consumption from the Version 4.2 April 2015 page 5 of 25

6 patient or other informant in units of alcohol per week, withdrawal seizures, severe withdrawal and pattern of drinking: Did you have a drink today before coming to hospital? How much do you drink? How often do you drink? When was your last drink? Have you ever experienced alcohol withdrawal symptoms, such as sweats or tremors? Have you ever experienced withdrawal seizures or delirium tremens ( DTs )? Where the appropriate screening test and/or alcohol history cannot be completed, e.g. patient intoxicated, demented or confused, examination and investigations should inform initial assessment. Most patients with alcohol problems, including withdrawal can be managed in the community but in-patient detoxification is usually required if the patient: is confused or has hallucinations is severely dependent on alcohol is currently having (or has had) severe withdrawal symptoms such as delirium tremens or seizures has epilepsy or a history of fits suffers with a serious medical or psychiatric condition has multiple substance misuse is at risk of suicide or homicide lacks social support/supervision in the community has a history of failed community detoxifications has significant cognitive impairment Where the result of the appropriate alcohol screening test and the alcohol history suggest hazardous, harmful or dependant drinking, the following should be assessed: Physical/mental examination, including signs and symptoms of alcohol withdrawal: Mild symptoms Tense Irritable Poor concentration Moderate symptoms Tachycardia Nausea Tremor Sweats Anxiety Irritability Headache Flu-like symptoms Seizures Severe symptoms Confusion Visual/auditory hallucinations Irrational thoughts/fears Seizures Bizarre, aggressive, un-cooperative behaviour Version 4.2 April 2015 page 6 of 25

7 Any concurrent alcohol related illness/disease, e.g. alcoholic liver disease, Korsakoff s psychosis, peripheral neuropathy. Investigations: FBC, prothrombin time, U&Es, LFTs, GT, glucose, magnesium and calcium. Consider checking Blood Alcohol Concentration (BAC). It is also important to enquire about other substances of misuse. Consider urine drug screening. Refer to the NHS Forth Valley Guidance on Managing Substance Misuse in the In-patient Setting. Where the result of the appropriate alcohol screening test, and the history, examination and investigations confirm that the patient is in alcohol withdrawal or is at potential risk of alcohol withdrawal, the patient must be regularly assessed, monitored and treated. Where STT is authorised, the declaration in the Outcome Section of Appendix 1 should be recorded and signed by the Clinical Assessor. Examination for symptoms of Wernicke s encephalopathy must also be completed, as described in section 4. Treatment for symptoms of alcohol withdrawal is described in section 5. Management is summarised in appendix 4, Hospital Management of Alcohol Withdrawal Guidance Flowchart. It is important to refer promptly for specialist help and advice if required. Patients in Forth Valley Royal Hospital can be referred to the Hospital Addiction Team (HAT) (within hours) or on-call psychiatrist (out of hours). Specialist Contacts (FVRH in-patients) weekday service HOSPITAL ADDICTION TEAM or radio page 1051/1651 In other clinical areas the on-call psychiatrist should be contacted. 3.1 Patients who do not require pharmacological management of alcohol withdrawal Where the result of the appropriate alcohol screening test suggests hazardous, harmful or dependant drinking, offer the patient an Alcohol Brief Intervention (ABI). Refer to NHS Health Scotland Alcohol Brief Interventions (ABI) A&E Pack, Alcohol Brief Interventions (ABI) Professional Pack or Alcohol Brief Interventions (ABI) Antenatal Pack. Patients attending the Emergency Department who require and have accepted follow-up for an Alcohol Brief will be contacted by HAT to arrange an appointment. The following services should be offered: Useful Contacts Patient self-referral: SIGNPOST RECOVERY ALCOHOLICS ANONYMOUS ADDICTIONS SUPPORT & COUNSELLING (ASC) (Stirling) (Falkirk) Version 4.2 April 2015 page 7 of 25

8 Specialist psychiatric and psychological services are available to work closely with patients who have complex mental health issues and/or trauma as these issues may affect the patient s ability to remain abstinent. These services provide specialist support to pregnant alcohol users too. Referrals should be made via the Community Alcohol & Drug Service (CADS). Specialist Contact COMMUNITY ALCOHOL AND DRUG SERVICE Stirling: Falkirk: Recognition of Wernicke s Korsakoff Syndrome Wernicke s encephalopathy is a reversible biochemical lesion of the CNS caused by overwhelming metabolic demands being made upon depleted B-vitamin reserves, in particular thiamine. Wernicke s encephalopathy is most common in chronic alcohol misusers. Wernicke s encephalopathy is an acute illness, precipitated by alcohol withdrawal, which is often under treated or missed. It should be suspected and treated in any patients undergoing alcohol detoxification who develop confusion, memory problems or difficulties with their gait or co-ordination. A presumptive diagnosis of Wernicke s encephalopathy should be made in patients with a history of alcohol misuse and one or more of the following otherwise unexplained symptoms: Acute confusion or other cognitive problems Ophthalmoplegia/ nystagmus Ataxia/ unsteadiness Memory disturbance Decreased consciousness level including unconsciousness/ coma Unexplained hypotension with hypothermia Korsakoff s psychosis is described as an amnesic syndrome with impaired recent memory, and relatively intact intellectual function. It occurs after one or more inadequately treated episodes of Wernicke s encephalopathy. Patients rarely have a discrete deficit in forming new memories and often present with more global deficits along a spectrum of severity. Korsakoff s psychosis is a preventable dementia, by prompt treatment where Wernicke s is suspected, with high dose parenteral vitamin preparations. It is also important to elucidate, from a careful history, patients who are at risk of developing Wernicke-Korsakoff syndrome. These would include patients who have: physical illness weight loss poor diet diarrhoea vomiting These patients should also be treated with parenteral vitamins. Version 4.2 April 2015 page 8 of 25

9 4.1 Management of Patients with or at Risk of Wernicke s Encephalopathy ALL patients attending the ED, admitted or to be admitted to hospital, in alcohol withdrawal or at potential risk of alcohol withdrawal must be assessed for risk of developing Wernicke's encephalopathy and must be prescribed parenteral vitamins. The appropriate Pabrinex regimen should be completed by the prescriber on the Hospital Management of Alcohol Withdrawal Schedule (Appendix 5). Pabrinex must be administered before the administration of glucose or nutritional support. Where a presumptive diagnosis of Wernicke s encephalopathy is made, or where there is any clinical doubt as to whether the patient requires treatment or prophylaxis, patients must receive treatment doses of intravenous high potency vitamins B and C: Intravenous PABRINEX: TWO pairs of ampoules, THREE times daily for THREE days. (Note, for IV administration, mix No. 1 and No. 2 ampoules with 100ml of normal saline or 5% glucose and infuse over 30 minutes.) Where a response is noted, continue treatment with PABRINEX, either intravenously or intramuscularly, ONE pair of ampoules, ONCE daily for FIVE days. This will require to be prescribed on the main prescription chart. In patients with ataxia, polyneuritis and/or memory disturbance, continue treatment until clinical improvement ceases. Where no response is noted, discontinue supplementation unless the patient is comatose/unconscious or Wernicke s encephalopathy has been confirmed by other means. All other patients presenting in alcohol withdrawal or at potential risk of alcohol withdrawal should receive prophylactic doses of intravenous or intramuscular high potency vitamins B and C: Intravenous or intramuscular PABRINEX: ONE pair of ampoules, ONCE daily for THREE days. There is a very small risk of anaphylaxis with parenteral vitamin preparations. The risk is less with intramuscular administration. Facilities for treatment of anaphylaxis should be available. Guidance on Pabrinex dosing is summarised in Appendix 6. Patient Information: Choice and Medication pabrinex leaflets may be accessed via NHS Inform. Oral preparations of thiamine are poorly absorbed in alcohol misusers, and will not adequately replace depleted thiamine stores. They should not be used as a substitute for parenteral preparations. Patients who have a chronic alcohol problem and whose diet may be deficient should be given oral thiamine indefinitely after parenteral administration (SIGN 74). For this group a dose of thiamine 100mg three times daily is recommended. Version 4.2 April 2015 page 9 of 25

10 5. Replacement of Alcohol with an Alternative CNS Depressant In Forth Valley, chlordiazepoxide is the agreed medicine of choice in the management of alcohol withdrawal symptoms and is a suitable medication in the majority of cases. Benzodiazepines have sedative, anxiolytic and anticonvulsant properties. They show cross-tolerance with alcohol, which is necessary in detoxification. It is important to regularly assess the patient for signs and symptoms of withdrawal throughout the detoxification period. Signs and symptoms occur within hours of the last drink and peak around hours. In cases of severe liver impairment, i.e. jaundice with decreased synthetic function, discuss with the on-call gastroenterologist. For the small number of patients with severely impaired liver function, a short-acting benzodiazepine (e.g. lorazepam) or lower doses of chlordiazepoxide should be considered to avoid build up of metabolites and over sedation. It is recommended that single doses of chlordiazepoxide for any patient do not exceed 45mg without first consulting with a doctor or the Hospital Addiction Team. More severe cases of alcohol dependence may need a larger starting dose. Patients using benzodiazepines prior to admission may also require larger doses to be prescribed. Refer for specialist review. Patients with severe symptoms of withdrawal or at risk of withdrawal seizures must be prescribed rectal diazepam solution 10mg or alternative medication, 'as required'. Patients should be orientated and reassured that any distressing symptoms will eventually settle. An explanation of the symptoms and their relationship to excessive alcohol consumption should be given. 5.1 Symptom Triggered Dosing of Chlordiazepoxide for Alcohol Withdrawal A management of alcohol withdrawal guidance flowchart is contained in appendix 4. This should be read in conjunction with the notes below and the detailed advice of the guideline. CAUTION with chlordiazepoxide dosing in patients with: decompensated liver disease, respiratory disease, sepsis and patients (including elderly) where alternative organic cause for delirium/confusion is suspected. For patients in severe withdrawal or unable to tolerate oral medication, seek senior medical or psychiatric advice. ALWAYS ensure that emergency resuscitation equipment and medication, including the benzodiazepine antagonist flumazenil is present before administering parenteral benzodiazepines. The Hospital Management of Alcohol Withdrawal Schedule should be completed and signed by the prescriber (Appendix 5). Ensure the appropriate Pabrinex regimen is completed. Management of Alcohol Withdrawal Schedule must also be prescribed on the regular section of the prescription chart. Version 4.2 April 2015 page 10 of 25

11 Through regular assessment and monitoring of the patient, each sign/symptom is rated to establish a total score which determines the appropriate dose of chlordiazepoxide to be administered. Scores, total scores and doses of chlordiazepoxide administered should be documented on the Alcohol Withdrawal Schedule. If the patient is asleep, they should be woken for assessment and monitoring. Caution is advised in the interpretation of scores in patients who are intoxicated or have a head injury. Chlordiazepoxide doses must NOT be administered more frequently than ONE HOURLY. If a total dose of chlordiazepoxide 240mg (aged 18-64), or 60mg (aged 65 and over) in 24 hours has been administered and the patient requires more, or if symptoms are not controlled after six consecutive doses, request senior medical review. Refer to the liaison psychiatry team ( ) or on-call psychiatrist (out of hours) for further advice if required. Assessment and monitoring should continue for 12 hours after a score of less than two is recorded and no chlordiazepoxide is administered during this time. If the patient requires doses of chlordiazepoxide beyond seven days, request specialist review by the liaison psychiatrist team. Patient Information: Choice and Medication chlordiazepoxide leaflets may be accessed via NHS Inform. 6. Monitoring Patients admitted in alcohol withdrawal or at potential risk of alcohol withdrawal in whom the Hospital Management of Alcohol Withdrawal Schedule has been commenced should be assessed and monitored according to this schedule and the guidance flow chart in Appendix 4. Initially they should be assessed and monitored every two hours. Where withdrawal symptoms are not controlled, monitoring and assessment should increase to hourly, and reduce to two hourly only when symptoms are controlled and scores stabilise or reduce. Following 12 hours of monitoring and assessment during which time scores are stable or reducing, and the patient s symptoms are controlled, reduce to four hourly. Vital signs should be monitored throughout the detoxification period and recorded using the NHS Early Warning Score/ Physical Monitoring Chart. Necessary interventions should be made where indicated. Assessment and monitoring of the patient should continue for 12 hours after a score of less than two is recorded on the Hospital Management of Alcohol Withdrawal Schedule and no chlordiazepoxide has been administered during this time. Undertake routine checks on serum urea and electrolytes. Encourage adequate oral fluid intake i.e litres/ day. Version 4.2 April 2015 page 11 of 25

12 7. Management of Disturbed Patients and those with Complex Needs It is essential to ensure that patients are given adequate, early benzodiazepine treatment. Most cases of difficult to manage patients are avoidable. Where difficulties are arising, it should first be checked that adequate chlordiazepoxide has been given. Mild perceptual disturbances usually respond to chlordiazepoxide. Patients presenting with psychotic symptoms such as hallucinations warrant referral to the liaison/consultant psychiatrist. Consider treatment with oral or intramuscular haloperidol 5mg (0.5-2mg in elderly/frail), in discussion with senior medical staff. Refer also to the NHS Forth Valley Emergency Sedation Guidelines. Relevant legislation, e.g. Adults with Incapacity Act, is also discussed in these guidelines. Refractory alcohol withdrawal delirium (AWD) exists where the equivalence of 20mg of diazepam per hour has been used over a period of three hours and the patient continues to be agitated, or where the patient is scoring above 35 on the CIWA-Ar score, despite treatment with benzodiazepines. Referral to both medical and/or intensive care should be made for further management of these patients as soon as a diagnosis of refractory AWD is made. It is unsafe to treat individuals with refractory AWD without cardiac telemetry, due to the risk of arrhythmias, oxygen and intubation equipment, due to the risk of respiratory arrest. Note, haloperidol can reduce seizure threshold; ensure rectal diazepam or alternative medication is available. Haloperidol may cause extrapyramidal side effects; ensure an anticholinergic, e.g. procyclidine is available. 8. Management of Older People with Complex Needs Older people often have complex morbidities including pre-existing dementia, mobility problems and cerebrovascular disease, which further add to the difficulty in recognising the problems of alcohol misuse in this age group, and may complicate management. Lower doses of medications may be indicated. Specialist help and advice is available from the Hospital Addiction Team and Old Age Liaison Psychiatry Team. NHS Forth Valley Emergency Sedation Guidelines provide guidance on the management of acutely disturbed older people (refer also to notes in section 7). Refer to the older peoples consultant psychiatrist for further advice. Version 4.2 April 2015 page 12 of 25

13 9. Discharge Planning The need for in-patient alcohol detoxification means that the patient has a dependency on alcohol, and by definition a severe alcohol problem. It is important that all avenues to prevent relapse are explored, and that patients are offered pharmacological, psychological and social help for their dependence. 9.1 Pharmacological Interventions Patients should be given no more than seven days chlordiazepoxide without specialist review. If patients undergo a planned discharge, they may complete their detoxification at home. A discharge prescription for chlordiazepoxide will be dependent on the assessment scoring and discharge plan. Refer to the Hospital Addiction Team or liaison/consultant psychiatrist where necessary. For patients who take their own discharge out with the recommended treatment plan, the risk of under-treated delirium tremens must be carefully considered. The decision to continue the chlordiazepoxide reducing prescription must be taken cautiously by the clinician for each individual case. If it is felt that the patient will continue to drink, it may be appropriate to consider a prescription for thiamine at a dose of 100mg three times per day. This is not necessary if the patient is eating a normal diet. Patients who have a chronic alcohol problem and whose diet may be deficient should be given oral thiamine indefinitely. There are medications which can aid maintenance of abstinence, such as acamprosate and disulfiram. Guidance on the prescribing of these medicines is detailed in NHS Forth Valley Guidance on Alcohol Dependence: Maintenance of Abstinence. Advice is also available from the Hospital Addiction Team or liaison/ consultant psychiatrist. 9.2 Psychological and Social help There are a number of agencies in Forth Valley who offer counselling and support to substance users. These include Alcoholics Anonymous (AA), Alcohol Support Counselling (ASC) and Signpost Recovery. Useful Contacts Patient self-referral: SIGNPOST RECOVERY ALCOHOLICS ANONYMOUS ADDICTIONS SUPPORT & COUNSELLING (ASC) (Stirling) (Falkirk) For further details, refer to the NHS Forth Valley Guidance on Alcohol Dependence: Maintenance of Abstinence. Version 4.2 April 2015 page 13 of 25

14 10. References The following national guidelines and references support this local guideline: 1. Cook, C.H., Thomson, A.D., B-Complex Vitamins in the prophylaxis and treatment of Wernicke-Korsakoff syndrome, Br J Hosp Med 1997; 57: Lingford-Hughes A.R., Welch S., Nutt D.J., Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 2004; 18(3): McIntosh, C., Chick, J., Alcohol and the Nervous System, JNNP 2004; (suppl III): iii16- iii Raistrick D., Heather N., Godfray C. Review of the effectiveness of treatment for alcohol problems. National Treatment Agency. 5. Scottish Intercollegiate Guidelines Network (SIGN). The management of harmful drinking and alcohol dependence in primary care, Slattery, J., Chick, J., et al Prevention of relapse in alcohol dependence, Health Technology Assessment Report 3, 2003, NHS-QIS. 7. Thomson A.D., Marshall E.J., The natural history and pathophysiology of Wernicke s Encephalopathy and Korsakoff s Psychosis. Alcohol & Alcoholism 2006; 4 (No 2): Thomson A.D., Marshall E.J., The treatment of patients at risk of developing Wernicke s Encephalopathy in the community, Alcohol & Alcoholism 2006; 41(No 2): Alcohol-use disorders. Diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100. June Alcohol-use disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115. February Our Invisible Addicts. First Report of the Older Persons Substance Misuse Working Group of the Royal College of Psychiatrists. College Report CR165. June Alcohol-use disorders: sample chlordiazepoxide dosing regimens for use in managing alcohol withdrawal. NICE clinical guidelines 100 and 115. February Blow, F.C. (1991). Short Michigan Alcoholism Screening Test Geriatric Version (SMAST-G). Ann Arbor, MI: University of Michigan Alcohol Research Center. Internet/Intranet Links 1. NHS Health Scotland Alcohol Brief Interventions (ABI) A&E Pack 2. NHS Forth Valley Guidance on Managing Substance Misuse in the In-patient Setting 3. NHS Health Scotland Alcohol Brief Interventions (ABI) Primary Care Pack 4. NHS Health Scotland Alcohol Brief Interventions (ABI) Antenatal Pack 5. Choice and Medication patient leaflets Version 4.2 April 2015 page 14 of 25

15 7. NHS Forth Valley Emergency Sedation Guidelines 8. NHS Forth Valley Guidance on Alcohol Dependence: Maintenance of Abstinence Version 4.2 April 2015 page 15 of 25

16 1. Screen (addressograph) Fast Alcohol Screening Test (FAST) Patient Score Chart Name of person completing chart: Appendix 1 Patient s name:.. CHI Number:.. Contact telephone number:.... Department:. Date:.. Questions Scoring system Score How often do you have SIX or more units if female, or EIGHT or more if male, on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Only answer the following questions if the answer above is Less than monthly (1) or Monthly (2). Stop here if the answer is Never (0), Weekly (3) or Daily (4). How often during the last year have you been unable to remember what happened the night before because you had been drinking? How often during the last year have you failed to do what Was normally expected of you because of drink? Never Never Less than monthly Less than monthly Monthly Monthly Weekly Weekly Daily or almost daily Daily or almost daily In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? No Yes, on one occasion Yes, on more than one occasion Scores: FAST 0-2 (FAST negative): Low risk of alcohol misuse advise on safe drinking levels FAST 3-16 (FAST positive): Hazardous, harmful or dependent drinking advise on safe drinking levels, offer an Alcohol Brief Intervention (ABI) and alcohol information pack. Consider specialist referral. SCORE Please tick 1, 2, 3 or 4 and consider if 5 appropriate: 1. ABI NOT indicated (FAST score less than 3) 2. ABI indicated but patient declined 3. ABI indicated and admitted to hospital 4. Discussion about alcohol/abi completed in department and advice/information given 5. Patient suitable for and agreeable to Hospital Addiction Team (HAT) follow-up * * Patients attending the Emergency Department who require and accept follow-up will be contacted by HAT to arrange an appointment. 2. Clinical Assessment Assess alcohol history, examination and investigation to confirm if the patient is in alcohol withdrawal or is at potential risk of alcohol withdrawal (see Section 3). 3. Outcome Patient has been clinically assessed as requiring Symptom Triggered Treatment (STT) YES NO Signature... Date... CAUTION with chlordiazepoxide dosing in patients with: decompensated liver disease, respiratory disease, sepsis and patients (including elderly) where alternative organic cause for delirium/confusion is suspected. Version 4.2 April 2015 page 16 of 25

17 Antenatal Alcohol Screening Test Appendix 2 Version 4.2 April 2015 page 17 of 25

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19 (addressograph) Short Michigan Alcoholism Screening Test Geriatric Version (SMAST-G) Patient Score Chart Appendix 3 Name of person completing chart: Patient s name:.. CHI Number:.. Contact telephone number:.... Department:. Date:.. Questions Scoring system When talking with others, do you ever underestimate how much you drink? No Yes 2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn t feel hungry? 3. Does having a few drinks help decrease your shakiness or tremors? No Yes 4. Does alcohol sometimes make it hard for you to remember parts of the day or night? 5. Do you usually take a drink to relax or calm your nerves? No Yes 6. Do you drink to take your mind off your problems? No Yes 7. Have you ever increased your drinking after experiencing a loss in your life? No Yes 8. Has a doctor or nurse ever said they were worried or concerned about your drinking? No Yes 9. Have you ever made rules to manage your drinking? No Yes 10. When you feel lonely, does having a drink help? The Regents of the University of Michigan, Reprinted with permission to use in NHS Forth Valley granted by Dr Frederic C. Blow, Ph.D., University of Michigan 15/11/12 No No No Yes Yes Yes Score Scores: SMAST-G 0-1: Low risk of alcohol misuse advice on safe drinking levels SCORE SMAST-G 2-10: Possible hazardous, harmful or dependent drinking advise on safe drinking levels, offer an Alcohol Brief Intervention (ABI) and alcohol information pack. Consider specialist referral Please tick 1, 2, 3 or 4 and consider if 5 appropriate: 1. ABI NOT indicated (FAST score less than 3) 2. ABI indicated but patient declined 3. ABI indicated and admitted to hospital 4. Discussion about alcohol/abi completed in department and advice/information given 5. Patient suitable for and agreeable to Hospital Addiction Team (HAT) follow-up * * Patients attending the Emergency Department who require and accept follow-up will be contacted by HAT to arrange an appointment. Version 4.2 April 2015 page 19 of 25

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22 Appendix 6 Guidance Flowchart Management of Patients With or at Risk of Wernicke s Encephalopathy This guidance must be used in conjunction with NHS Forth Valley Guidance on Alcohol Dependence: Hospital Management of Alcohol Withdrawal (Emergency Department and in-patient setting). Alcohol dependence identified via screening process and confirmed by alcohol history, examination and investigations Presumptive diagnosis of Wernicke s encephalopathy If any one of: Confusion Memory loss Reduced conscious level Ataxia Nystagmus Ophthalmoplegia Hypothermia with hypotension Where there is any clinical doubt over diagnosis or risk of Wernicke s encephalopathy Treatment Administer 2 pairs of IV PABRINEX ampoules (Parenteral High Potency Vitamins B and C) THREE TIMES DAILY for 3 DAYS. (Mix No. 1 and No. 2 amps with 100ml of normal saline or 5% glucose and infuse over 30 minutes) At risk of Wernicke s encephalopathy ALL other in-patients presenting in alcohol withdrawal or with potential for alcohol withdrawal Prophylaxis Administer ONE pair of IV or IM PABRINEX ampoules (Parenteral High Potency Vitamins B and C) ONCE DAILY for 3 DAYS. (IV: Mix No. 1 and No. 2 amps with 100ml of normal saline or 5% glucose and infuse over 30 minutes.) Response 1 pair IV or IM Pabrinex amps ONCE DAILY for 5 DAYS In patients with ataxia, polyneuritis, memory disturbance - continue treatment until clinical improvement ceases. No Response Discontinue supplementation unless comatose/ unconscious or Wernicke's encephalopathy confirmed by other means. If symptoms persist consider neurological review Small risk of anaphylactic reactions with parenteral vitamin preparations. Risk is less with intramuscular administration. Facilities for treatment of anaphylaxis should be available. Version 4.2 April 2015 page 22 of 25

23 Appendix 7 Symptom Triggered Treatment (STT) for Alcohol Withdrawal Care Bundle Audit The care bundle measures are applicable to patients who have been assessed and deemed appropriate for an inpatient detoxification treatment in Forth Valley Royal Hospital. Evidencing and Improving Care Using the collection tool a review of 5 patients per week should be undertaken to assess compliance with the care bundle measures. The Hospital Addiction Team (HAT) can provide further information on data collection and analysis of compliance with care bundle. More information on care bundles can be found on the Institute of Healthcare Improvement s (IHI) website: All measures must be met in their entirety, if this is the case indicate yes, otherwise no. Explanation is given below where some variances may apply and what to record in these cases. Measure 1 Has the Alcohol screening been completed by the ward staff? Indicate YES if the alcohol screening has been completed in full by the ward staff. If there is any information missing from the admission checklist, indicate NO. Measure 2 Has the patient received 2 hourly monitoring for the first 12 hours? Indicate YES if the patient has received 2 hourly monitoring for the first 12 hours after admitted. Where a patient s monitoring score increases, this may require monitoring to be reduced to hourly. In this case, also indicate YES. Otherwise, indicate NO. Measure 3 Has the patient received the prophylactic pabrinex dose as per alcohol withdrawal schedule? (I pair OD) Indicate YES where the patient has received the therapeutic Pabrinex dose as per alcohol withdrawal schedule. Where the patient requires the treatment dose (2 pairs TDS) also indicate YES. Otherwise, indicate NO. Measure 4 Has the monitoring been reduced after 24 hours to 4 hourly as per alcohol withdrawal flowchart? Indicate YES where monitoring has been reduced after 24 hours to 4 hourly as per alcohol withdrawal flowchart. Where the patient has a triggered increased dose with scoring requiring higher doses of medication, also indicate YES. Otherwise indicate NO. Measure 5 Avoidance of alcoholic seizures achieved Indicate YES If there is no evidence of alcoholic seizures either in the patient notes and no evidence of prescription or administration of PR Diazepam. Otherwise, indicate NO. Composite measure Have all 5 measures been achieved for each patient? Check whether each patient has received all 5 measures. Record those who have achieved this in the overall composite box. Version 4.2 April 2015 page 23 of 25 STT for Alcohol Withdrawal Care Bundle Data Collection Documentation, M MacKinnon, September 2013, v4

24 STT for Alcohol Withdrawal Care Bundle Appendix 7 Data Collection Tool Week commencing (enter date): Measure 1 Has the Alcohol screening been completed by the ward staff? Measure 2 Has the patient received 2 hourly monitoring for the first 12 hours? Measure 3 Has the patient received the prophylactic Pabrinex dose as per alcohol withdrawal schedule? (I pair once daily) Measure 4 Has the monitoring been reduced after 24 hours to 4 hourly as per alcohol withdrawal flowchart? Measure 5 Avoidance of alcoholic seizures achieved Composite measure Have all 5 measures been achieved for this patient Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Overall Composite 5 (How many patients have received all 5 measures?) Version 4.2 April 2015 page 24 of 25

25 Version 4.2 April 2015 page 25 of 25 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - fv-uhb.nhsfv-alternativeformats@nhs.net