PAT/T 25
v.3
Alcohol Issues in the Acute General
Hospital Setting
(Guidelines and Management)
This procedural document supersedes: PAT/T 25 version 2 - Guidelines for the Management of
Alcohol Issues in the Acute General Hospital Setting
Did you print this document yourself?
The Trust discourages the retention of hard copies of policies and can only guarantee that the
policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need
to print a policy off, it is only valid for 24 hours.
Author/reviewer: (this
version)
Shane Peagram – Drug & Alcohol Liaison Nurse
Specialist
Date written/revised:
April 2014
Approved by:
Policy Approval and Compliance Group
Date of approval:
22 October 2014
Date issued:
29 October 2014
Next review date:
April 2017
Target audience:
Trust-wide
Page 1 of 41
PAT/T 25
v.3
Amendment Form
Please record brief details of the changes made alongside the next version number. If the
procedural document has been reviewed without change, this information will still need to be
recorded although the version number will remain the same.
Version
Date Issued
Brief Summary of Changes
Version 3
29 October
2014
Revised layout to all sections to make the policy
more user friendly.


Version 2
January
2010





Version 1
June 2006
Author
S Peagram
Section 8 – now includes a greater choice of
drug regimens in keeping with NICE
guidance.
Section 9 – clear guidance on discharge
arrangements for patients undergoing detox
across a wide range of scenarios.
Section 1 - Background information updated
to include current national, regional and
local strategies
Section 2 - Reference made to the new Trust
alcohol screening and care pathway
[Appendix 1 and 2]
Section 4 - Throughout the general
management there are various aspects of
treatment and prescribing amendments as
advised by Lee Wilson - Consultant
Pharmacist. Included in this edition are
notes regarding rapid tranquillisation;
[supported by Shane Peagram –Drug &
Alcohol Liaison Nurse Specialist DR1] also
added is Nutritional Management of
Alcoholic Liver Disease [submitted by Vera
Todorovic - Consultant Dietitian]
Revised reference
Revised Appendices
New Document
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V Wood
V Wood
PAT/T 25
v.3
Contents
Page
No.
Section
1
INTRODUCTION
6
2
PURPOSE
6
3
DUTIES and RESPONSIBILITIES
6
3.1 Working with people who misuse alcohol
6
3.2 Doctors Responsibilities
7
3.3 Prescribers Responsibilities
7
3.4 DANS Responsibilities
7
3.5 Nurses Responsibilities
7
3.6 Patient Responsibilities
7
BACKGROUND
8
4.1 Current Advised Drinking Limits
8
4.2 Risk of Harm from Excess Alcohol
8
4.3 Binge Drinking
9
4.4 Dependent Drinking
9
SCREENING
10
5.1 FAST
10
5.2 A&E screening
10
5.3 Combined Risk Assessment Screening
11
5.4 Specialist Screening
11
ASSESSMENT
13
6.1 General Principles
13
6.2 Triage Assessment
13
6.3 Comprehensive Assessment
13
6.4 Examination
14
6.5 Investigations
14
6.6 Observations
15
4
5
6
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Page
No.
Section
7
8
9
10
v.3
ALCOHOL WITHDRAWAL SYNDROME
16
7.1 Set 1: Uncomplicated Withdrawal
16
7.2 Set 2: Hallucinations
16
7.3 Set 3: Seizures
17
7.4 Set 4: Delirium Tremens
17
7.5 Risk Factors for complex withdrawal
17
7.6 Protracted withdrawal
18
DETOXIFICATION REGIMENS
18
8.1 Low dose fixed regimen – Moderate Dependency
19
8.2 High dose fixed regimen – Severe Dependency
19
8.3 Very high dose fixed regimen – Very Severe Dependency
20
8.4 Symptom triggered regimen
20
8.5 JAC Electronic prescribing
21
8.6 Delirium Tremens
21
8.7 Hallucination
22
8.8 Seizure
23
8.9 Liver Disease
23
8.10 Nursing Management
24
DISCHARGE PLANNING
25
9.1 Self discharge
25
9.2 Non – compliance
25
9.3 Declines detox
26
9.4 Detox completed – Medically Fit
26
9.5 Incomplete Detox – Medically Fit
26
9.6 Maximum take home doses
27
WERNICKE’S ENCEPHALOPATHY
28
10.1 Background
28
10.2 Diagnosis
28
10.3 Treatment
29
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v.3
Page
No.
Section
11
TRAINING/SUPPORT
30
12
MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT
30
13
DEFINITIONS
30
14
EQUALITY IMPACT ASSESSMENT
31
15
ASSOCIATED TRUST PROCEDURAL DOCUMENTS
31
16
REFERENCES
31
Appendix 1
COMBINED RISK SCREENING AND ASSESSMENT DOCUMENT
(FAST)
33
Appendix 2
CIWA-AR
35
Appendix 3
AUDIT
36
Appendix 4
SADQ
37
Appendix 5
FAST ED
38
Appendix 6
EQUALITY IMPACT ASSESSMENT – SCREENING FORM
41
Appendices:
Page 5 of 41
PAT/T 25
1.
v.3
INTRODUCTION
These guidelines are intended for both medical and nursing staff, to act as a resource in the
screening of patients to identify risk of harm from alcohol AND the treatment of alcohol
dependency through medically managed withdrawal.
The main source of evidence used within these guidelines is taken from NICE (2010) CG100
Alcohol Use Disorders – Diagnosis and clinical management of alcohol – related physical
complications. NICE (2011) CG115 Alcohol Use Disorders – Diagnosis, assessment and
management of harmful drinking and alcohol dependence. And should be read in conjunction
with NICE (2010) PHG24 Alcohol Use Disorders – preventing the development of hazardous and
harmful drinking.
2.
PURPOSE
The purpose of these guidelines is to offer a comprehensive structure to our approach to alcohol
within the context of the Government’s Alcohol Strategy’s aims of:


Ensuring everyone is aware of the risks of excessive alcohol consumption and can make
informed choices about responsible drinking.
Recognising that some people will need support to change their behaviour and ensuring
that this is available, particularly for the most vulnerable in our communities.
“This strategy signals a radical change in the approach and seeks to turn the tide against
irresponsible drinking. Such change will not be achieved overnight.” HMSO (2012).
3.
DUTIES AND RESPONSIBILITIES
3.1
Working with people who misuse alcohol







Build a trusting relationship and work in a supportive, empathic and non-judgemental
manner.
Take into account that stigma and discrimination are often associated with alcohol
misuse and that those presenting to services may minimise their alcohol problem.
Hold discussions in settings in which confidentiality, privacy and dignity are respected.
Provide information appropriate to the individual’s level of understanding about the
nature and treatment of alcohol misuse to support their choice from a range of evidence
based treatments.
Make sure that comprehensive written information is available in an appropriate
language or in an accessible format.
Avoid clinical language without explanation.
Provide independent interpreters if needed.
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3.2
v.3
Doctors’ responsibilities
The Doctor responsible for the patient will ensure a triage assessment [Sec 6.2], of alcohol
intake including the risk of alcohol withdrawal syndrome and Wernicke’s encephalopathy [Sec
10], is undertaken upon admission to hospital and where necessary immediate treatment
initiated. [Sec 8]
A risk assessment is also required as part of discharge planning. [Sec 9]
3.3
Prescribers’ responsibilities
The prescriber will ensure a triage assessment [Sec 6.2] of alcohol intake, including the risk of
alcohol withdrawal syndrome and Wernicke’s encephalopathy [Sec 10], is undertaken prior to
prescribing.
In the case of non medical prescribers, prescribing will only take place where the prescriber is
feels competent to do so. [Sec 8]
Prescribers must ensure an adequate risk assessment is carried out as part of discharge planning
process. [Sec 9]
3.4
DANS responsibilities
The Drug and Alcohol Liaison Nurse Specialist (DANS) will ensure a comprehensive assessment of
alcohol intake [Sec 6.3] including risk of dependence, severity of dependence, risk of Wernicke’s
encephalopathy [Sec 10], social support networks, motivation to change and safe discharge plan
are undertaken. [Sec 9]
3.5
Nurses’ responsibilities
The nursing staff is responsible for screening patients for risk of harm from alcohol intake as part
of the Combined Risk Screening and Assessment Document for all inpatients. [APPENDIX 1]
For patients requiring detoxification nursing staff are expected to complete the required physical
observations at the frequency dictated by the clinical assessment tool CIWA-AR [APPENDIX 2].
3.6
Patients’ responsibilities
The patient is expected to engage with the screening and assessment process providing a true
and honest account of their alcohol intake in order to ensure safe and appropriate treatment.
For patients requiring detoxification there is an expectation that they remain drug and alcohol
free throughout in order to ensure safe treatment.
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v.3
Where there is reason to believe patients are non compliant with the detoxification and the
patient is medically fit and has capacity the patient will be discharged without take home
medication.
4.
BACKGROUND
The risk of harm from alcohol increases the more you drink, AND the more often you drink. By
helping people to understand the risk of harm associated with their alcohol intake we enable
them to make better informed lifestyle choices.
4.1
Current Advised Drinking Limits
Men
Women
Daily units
3–4
2–3
Weekly units
21
14
Days Off per week
2
2
Adults are advised not to exceed daily drinking limits on any given day and not to exceed weekly
totals. In order to reduce the risk of harm from alcohol further they are advised to have a
minimum of 2 (non consecutive) alcohol free days per week.
4.2
Risk of Harm from Excess Alcohol
The level of risk is linked to the total alcohol intake and can be assessed by calculating the total
number of units of alcohol consumed per week.
In the UK 1 unit alcohol = 8g (10mls) Ethanol.
Total units = vol mls / 1000 x ABV %
Risk Level
Low Risk
(Sensible)
(Safe)
Increasing Risk
(Hazardous)
Men
<21 units / week
Women
<14 units / week
22-49 units / week
15-35 units / week
Higher Risk
(Harmful)
50+ units / week
36+ units / week
Common effects
Increased relaxation
Reduced risk heart disease
Sociability
Less energy
Depression / stress
Insomnia
Risk of injury
High blood pressure
All of the above and
Memory loss
Liver disease
Cancer
Alcohol dependence
Avoid terms such as Social, Heavy or Excessive to describe alcohol intake
Page 8 of 41
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v.3
Alcohol Dependency or Alcohol Dependent are preferred to Alcoholic, known alcoholic or
Addict.
Screening tools such as AUDIT [APPENDIX 3], FAST [APPENDIX 1] and SADQ [APPENDIX 4] are
useful to aid the assessment process. [Sec 6]
4.3
Binge Drinking
A person is said to be Binge Drinking when they have consumed more than twice the guidance
amounts in any one session. E.g.
Women - 6 units / day
Men – 8 units / day
Binge drinking is essentially drinking too much alcohol over a short period of time and it typically
leads to drunkenness. It has immediate and short-term risks to the drinker and to those around
them.
People who become drunk are much more likely to be involved in an accident or assault, be
charged with a criminal offence, contract a sexually transmitted disease and, for women, are
more likely to have an unplanned pregnancy.
Regular and repeated Binge drinking is associated with an increased Risk of Harm from alcohol.
Binge drinkers may also be at risk of dependency, where the binge episodes extend for periods
of several days OR weeks.
4.4
Dependent Drinking
In England, 4% of people between 16 and 65 are dependent on alcohol (6% men 2% women)
Alcohol Dependence: characterised by craving, tolerance, a preoccupation with alcohol in spite
of harmful consequences, physical withdrawal syndrome.
While most patients who experience alcohol dependency are aware of their condition and will
inform medical staff others might not be or are in denial. The use of assessment tools such as
the SADQ can aid diagnosis and highlight risk of complication. [APPENDIX 4]
Mild alcohol dependence: a score of 15 or less on SADQ.
Moderate alcohol dependence: a score of 15 – 30 on SADQ.
Severe alcohol dependence: a score of 30 – 40 on SADQ.
Very severe alcohol dependence: a score of 40-60 on SADQ
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5.
v.3
SCREENING
Screening is a systematic process of identifying people whose alcohol consumption places them
at increased risk of physical, psychological or social problems and who would benefit from a
preventative intervention. Questionnaire based screening is accurate, minimally intrusive and
has been found to be acceptable to recipients. (Wallace 2001)
While screening will inevitably highlight people who are physically dependent on alcohol these
patients are not the reason why we screen. Screening aims to identify the non dependent
drinkers whose current lifestyle of frequent exposure to alcohol significantly increases their risk
of chronic illness i.e. heart disease, liver disease and cancer.
For this reason NICE PHG 24 2010 requires that ;
“All NHS professionals should routinely carry out screening as an integral part of practice”
5.1
FAST
NICE recommends the use of a validated alcohol questionnaire such as AUDIT, FAST or PAT.
Across the Trust the FAST [APPENDIX 1] has been chosen, as the preferred tool for screening as it
is:
•
•
•
•
•
•
Reliable – identifies 930 per thousand
Quick – as little as 12 seconds
Terminated after one question for 60% patients
Cost effective - £1669 per 50,000 screens by an E Grade equivalent nurse
Acceptable to patients – 77% would take literature, 46% would welcome further
discussion.
Already in use as part of Combined Risk Assessment
(AERC – Alcohol Education Research council)
The FAST is for use within the Accident & Emergency Department [APPENDIX 5] and is included
within the Combined Risk Screening and Assessment Document for all inpatients. [APPENDIX 1]
5.2
A&E Screening
The FAST [APPENDIX 5] has been adapted for use in the Emergency Department where it is used
as a targeted assessment tool for patients presenting with one or more of the “top ten”
conditions linked to increased alcohol intake.
Patients who test positive are given feedback about their level of risk of harm from their lifestyle
and offered supporting literature and / or a referral to specialist community alcohol services.
Where patients present to A&E with a condition not included in the “top ten” screening is not
required.
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5.3
v.3
Combined Risk Assessment Screening
All inpatients are required to have a Combined Risk Screening and Assessment completed within
24hrs of admission to a ward (WPR 23084), contained within this is an Alcohol Screening with
FAST. [APPENDIX 1]
Patients who test positive for risk of harm from alcohol using FAST are offered the opportunity
to see a specialist alcohol health worker.
5.4
Specialist Screening
Where a patient has screened positive for FAST and is referred to the Drug and Alcohol Specialist
Nurse (DANS) an initial triage assessment will take place [sec 6.2] and where the patients
condition allows it a comprehensive alcohol assessment will be undertaken [sec 6.3]
Included within the DANS comprehensive assessment is the use the AUDIT Screening Tool
[APPENDIX 3] to identify the patients Risk of Dependency.
An AUDIT score of >20 indicates possible dependence and an additional SADQ Screening
[APPENDIX 4] to establish Severity of Dependence is required.
The results of the AUDIT and SADQ combined with the detailed alcohol history will guide the
clinicians in deciding which if any detox regimen is required. [sec 8]
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PAT/T 25
6.
ASSESSMENT
6.1
General Principles
v.3
On admission to an acute hospital patients may be unwell with an array of complex and pressing
physical health problems. These problems can be exacerbated by the onset of physical
withdrawal from alcohol.
It is therefore necessary to include an alcohol risk assessment (triage assessment) as early as
possible in the patient admission process. The extent of the assessment should be sufficient to
identify immediate risks without impeding the broader patient assessment.
6.2
Triage Assessment
A triage assessment must be completed during medical clerking or on testing FAST Positive [5.1]
during the completion of the nursing Combined Risk Screening and Assessment [APPENDIX 1].
The triage assessment should consider
 Pattern and severity of alcohol misuse and severity of dependence.
 The need for urgent treatment including assisted withdrawal
 Any associated risks to self or others
 The presence of any co-morbidity or other factors that may need further specialist
assessments or intervention.
The Triage assessment agrees the initial plan, taking into account the service user’s preferences
and outcomes of any previous treatments. [NTA, 2005]
6.3
Comprehensive Assessment
A comprehensive assessment should assess multiple areas of need, be structured in a clinical
interview, use relevant and validated clinical tools, and cover the following areas:








alcohol consumption, dependence and alcohol-related problems
co-existing health conditions, including co-existing drug and mental health problems
cognitive functioning
risk of harm to self and others
urgency for treatment
motivation and readiness to change
socio-demographic data
family relationships, social functioning
The Drug and Alcohol nurse specialist will undertake the comprehensive assessment.

Any child protection issues that might arise during the assessment must be address
following the appropriate local Area Child Protect Committee guidelines.
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6.4
v.3
Examination
Patients who misuse alcohol may appear to be sober and unexceptional upon attendance. They
might not yet display signs of withdrawal [Sec 7] or may have symptoms overlooked during an
incurrent illness, [DTB, 1991].
There are number of specific physical signs when present are highly suggestive of liver disease as
a result of alcohol abuse and should be specifically sought and recorded if this diagnosis is being
considered. :




6.5
Spider naevi
Telangiectasia
Facial mooning
Parotid enlargement



Palmer erythema
Dupuytren’s contracture
Gynaecomastia
Investigations
Patients who present acutely with decompensated liver disease, and who drink alcohol at a
potentially harmful level, should not be assumed to have alcohol-related liver disease. A full
assessment to exclude all other potential causes of liver disease should be performed as soon as
possible after admission to hospital. Consent must be obtained prior to further investigation.
Laboratory Investigations
 Haemoglobin
 Urea & Electrolytes, Creatinine
 Liver function tests, GGT
 Glucose
 Magnesium levels
Assessment of liver disease
 Non invasive Liver Screen
 Abdominal ultrasound
TABLE 1 - LABORATORY MARKERS THAT INDICATE ALCOHOL EXCESS [RCP, 2001]
Blood and breath alcohol
 A raised blood or breath alcohol is firm evidence of recent alcohol consumption.
However alcohol is metabolised rapidly and absence of alcohol indicates only that
alcohol has not been consumed in the past few hours.
Erythrocyte Mean Corpuscular Volume [MCV]
 MCV is raised in many chronic heavy drinkers but may also be raised for other
reasons.
Gamma glutamyl trasferase [GGT]
 GGT is a liver enzyme raised in a high proportion of chronic heavy drinkers but
returns to normal levels after about 5 week’s abstinence. It may also be raised in
non-alcoholic liver disease an in patients taking enzyme-inducing drugs.
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v.3
Aspartate amino transferase [AST]
 The liver enzyme AST is raise after heavy binge drinking but returns to normal within
48 hours. It may also be raised for other reasons.
Carbohydrate deficient transferrin [CDT]
 CDT is raised in some heavy drinkers. It is more specific than AST,GGT, or MCV
[Stribler, 1991]
Conclusion
Whilst laboratory markers may provide corroboratory evidence of hazardous drinking in
patients where this is suspected, none are sensitive or specific enough to be used in isolation,
nor can they distinguish hazardous drinkers from alcohol-dependant patients. The results need
to be supported by an assessment of the patient’s alcohol history.
6.6
Nursing Observations
In the general hospital, setting alcohol withdrawal is usually accompanied by a serious acute
illness, signs and symptoms may not be obvious, assessment may be difficult, and yet the
consequences of inadequate or excessive treatment are likely to be much more serious.
Repeated nursing observations using valid assessment tools are invaluable in identifying subtle
changes in the patient’s condition, allowing earlier intervention and management.
CIWA-Ar
An adaptation of the Addiction Research Foundation Clinical Institute’s Withdrawal Assessment
for Alcohol, Revised [CIWA-Ar] tool has been formatted for use in acute hospital settings.
[APPENDIX 2]
The CIWA-Ar tool must be initiated for all patients where alcohol withdrawal is present or
suspected.
The CIWA-Ar is repeated 4hrly initially and the subsequent frequency is dictated by the total
score.




Less than 10 repeat 4 hourly for 24 hrs
More than 10 repeat 2 hourly
More than 15 repeat 1 hourly
STOP once score less than 10 for 24hrs
At each assessment interval there is an opportunity to give additional medication in response to
developing symptoms.
The CIWA-Ar score can be used to determine when to initiate treatment for patients where
alcohol abuse is suspected but not established.
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

7.
v.3
Score 15 or more on two occasions
Score 20 or more on one occasion.
ALCOHOL WITHDRAWAL SYNDROME
Alcohol withdrawal syndrome occurs when people who are physically dependent upon alcohol
stop drinking or rapidly reduce their alcohol consumption.
Not all drinkers will experience withdrawal and those that do will present with a wide range of
symptoms described across 4 sets [Hall, 1997, Rubino, 1992, Turner, 1989]
AUDIT score of 20+ indicates possible dependency [APPENDIX 3]
SADQ scores indicate the severity of that Dependency [APPENDIX 4]
15 – 25 Units / day
SADQ 15 – 25
Moderate Dependency
7.1

50 – 60 units / day
SADQ 40 – 60
Very Severe Dependency
Set 1: Uncomplicated Withdrawal
Occurring within hours [typically 6-8 hours] of last drink and may develop before the blood
alcohol level has fallen to zero.
Peaking at 10-30 hours
Subsiding by 40 to 50 hours [Adinoff 1988, DTB,1991, Hall,1997, Morgan, 1998]
Characteristic tremor, starting in the hands but progressing to the head and trunk as severity
worsens.
Anxiety, restlessness, irritability, depression, insomnia and tiredness
Anorexia, nausea, and weakness.
Confusion
Signs and symptoms of autonomic arousal
 Sweating
 Tachycardia [100+bpm]
 Raised BP
 Fever [37-38 C]
 Hyperreflexia







7.2



30 – 49 units / day
SADQ 30 – 40
Severe Dependency
Set 2: Hallucinosis
Onset in the majority of cases is within 24 hours of last drink
Stopping within another 24-48 hours [Turner,1998]
Both auditory [frequently accusatory or derogatory voices] and visual [bugs crawling on the
bed, for example] hallucinations occur in otherwise clear sensorium. This is unlike delirium
tremens where sensorium is diffused and impaired.
[Chick, 2000, Rubino,1992, Turner, 1998]
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7.3





7.4
v.3
Set 3: Seizures
Can occur at 6 to 48 hours of alcohol cessation are more likely if there is a previous history of
withdrawal fits or epilepsy.
Rare beyond 48 hours following cessation. [Morgan, 1998]
They are characterised by major motor seizures that occur during withdrawal in patient who
normally have no seizures and have normal EEGs.
Fits tend to be single, generalised (if focal, suspect head injury) and may occur in bouts.
30% of cases are followed by DTs.
Set 4: Delirium Tremens
Onset of DTs is 2 to 5 days [most commonly at 2 to 3 days] following cessation and represents
a medical emergency. [Adinoff,1988, Erwin, 1998, CRAG 1994, Morgan, 1998, Rubino,1992]

Delirium tremens is the most severe manifestation of alcohol withdrawal. DTs occur in only
about 5% of patients undergoing alcohol withdrawal but account for the highest morbidity
and mortality.

DT’s usually occur in heavy drinkers who have
 minimised their consumption
 or withdrawn unexpectedly,
 been inadequately treated during withdrawal.

Patients consuming more than 16 units per day (½ to a bottle of spirits per day or
equivalent) are particularly at risk.

In addition to the classical symptoms of withdrawal the characteristic symptoms of DT’s are:
 Agitation, apprehension, confusion, disorientation in time and place, visual and
auditory hallucinations, insomnia, nausea, vomiting, motor inco-ordination and
paranoid ideation may be present.
 Fever is common.
 Poor concentration, intermittent disorientation and agitation may continue for 1-2
weeks before recovery.
7.5
Risk Factors for Complex Withdrawal
There is a risk of progression to severe / complex withdrawal and delirium tremens when the
patient with mild symptoms also have associated ‘risk factors’ [DBT, 1991, CRAG, 1994, RCP,
2001]

Concomitant use of other psychotropic drugs, high levels of anxiety, other psychiatric
disorders.
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


7.6
v.3
Poor physical health, hypoglycaemia, hypokalaemia [with respiratory alkalosis,
hypocalcaemia]
Fever, sweating, insomnia, tachycardia
Poor nutritional state
Protracted Withdrawal
Although not an official diagnosis protracted withdrawal has been noted in many alcohol
dependant patients. This disorder is characterised by irritability, emotional liability, insomnia
and anxiety that persist for weeks to months after alcohol withdrawal. It is due to the residual
effects of alcohol on the central nervous system and generally clears spontaneously after
prolonged abstinence. [Armstong, 2002]
8.
DETOXIFICATION REGIMENS
Withdrawal from alcohol can develop 6 -8 hours following cessation of drinking or upon
significant dose reduction in active drinkers resulting in autonomic arousal.
In order to safely manage the autonomic arousal associated with acute alcohol withdrawal
treatment with an appropriate Benzodiazepine is required.
The mainstay of treatment is Chlordiazepoxide. It is slowly absorbed, has a long half-life and low
potency. Adequate and timely dosing with Chlordiazepoxide usually prevents complications such
as withdrawal seizures.
The choice of detox regime should be based on the patients reported level of alcohol
consumption and severity of dependence. Clinical tools such as AUDIT, SADQ and CIWA-AR
inform the decision making process.
Nutritional support with parenteral Pabrinex 2 x pairs TDS is also required to prevent Wernickes
Encephalopathy.
The patients Liver Function and Renal output need to be taken into account to avoid potential
over sedation through accumulation.
Patients with grossly deranged Liver Function Tests / Decompensation should receive
treatment with Lorazepam at equivalent dosage [sec 8.9].
Page 18 of 41
PAT/T 25
8.1
Low Dose Fixed Regimen - Moderate Dependency
NOT SUITABLE FOR PATIENTS WITH ACUTE HEPATIC IMPAIRMENT or DECOMPENSATED
ALCOHOL RELATED LIVER DISEASE see [sec8.9].
For individuals displaying or reporting the need to relief drink to prevent physical withdrawal
from alcohol who drink 15 – 20 units / day or SADQ 15 - 25 daily OR who are frail.
Day 1
Chlordiazepoxide 20mg QDS
Pabrinex 2 x pair TDS
Day 2
Chlordiazepoxide 20mg QDS
Pabrinex 2 x pair TDS
Day 3
Chlordiazepoxide 15mg QDS
Pabrinex 2 x pair TDS
Day 4
Chlordiazepoxide 10mg QDS
Pabrinex 1 x pair OD*
Day 5
Chlordiazepoxide 10mg BD
Pabrinex 1 x pair OD*
Day 6
Chlordiazepoxide 10mg OD
Pabrinex 1 x pair OD*
PRN Chlordiazepoxide 20mg
Nursing staff able to administer Max 240mg Chlordiazepoxide (Routine + PRN) in 24hrs.
*IV Pabrinex can be discontinued Oral Thiamine initiated where there is no evidence of or
increased risk factors for Wernickes Encephalopathy.
8.2
High Dose Fixed Regimen – Severe Dependency
NOT SUITABLE FOR PATIENTS WITH ACUTE HEPATIC IMPAIRMENT or DECOMPENSATED
ALCOHOL RELATED LIVER DISEASE see [sec8.9]
For individuals displaying or reporting the need to relief drink to prevent physical withdrawal
from alcohol who drink 30 – 49 units / day or SADQ 30 - 40 daily.
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Chlordiazepoxide 30mg QDS
Chlordiazepoxide 30mg QDS
Chlordiazepoxide 25mg QDS
Chlordiazepoxide 20mg QDS
Chlordiazepoxide 15mg QDS
Chlordiazepoxide 10mg QDS
Chlordiazepoxide 10mg BD
Chlordiazepoxide 10mg OD
Pabrinex 2 x pairs TDS
Pabrinex 2 x pairs TDS
Pabrinex 2 x pairs TDS
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
PRN Chlordiazepoxide 30mg
Nursing staff able to administer Max 240mg Chlordiazepoxide (Routine + PRN) in 24hrs.
*IV Pabrinex can be discontinued Oral Thiamine initiated where there is no evidence of or
increased risk factors for Wernickes Encephalopathy.
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8.3
v.3
Very High Dose Fixed Regimen – Very Severe Dependency
NOT SUITABLE FOR PATIENTS WITH ACUTE HEPATIC IMPAIRMENT or DECOMPENSATED
ALCOHOL RELATED LIVER DISEASE see [sec8.9]
For individuals displaying or reporting the need to relief drink to prevent physical withdrawal
from alcohol who drink 50 – 60+ units / day or SADQ 40 - 60 daily.
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Chlordiazepoxide 45mg QDS
Chlordiazepoxide 40mg QDS
Chlordiazepoxide 35mg QDS
Chlordiazepoxide 30mg QDS
Chlordiazepoxide 25mg QDS
Chlordiazepoxide 20mg QDS
Chlordiazepoxide 15mg QDS
Chlordiazepoxide 10mg QDS
Chlordiazepoxide 10mg BD
Chlordiazepoxide 10mg OD
Pabrinex 2 x pairs TDS
Pabrinex 2 x pairs TDS
Pabrinex 2 x pairs TDS
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
Pabrinex 1 x pair OD*
PRN Chlordiazepoxide 30mg
Nursing staff able to administer Max 240mg Chlordiazepoxide (Routine + PRN) in 24hrs.
*IV Pabrinex can be discontinued Oral Thiamine initiated where there is no evidence of or
increased risk factors for Wernickes Encephalopathy
8.4
Symptom-Triggered Regimen (Chlordiazepoxide)
NOT SUITABLE FOR PATIENTS WITH ACUTE HEPATIC IMPAIRMENT or DECOMPENSATED
ALCOHOL RELATED LIVER DISEASE see [sec8.9]
Symptom-triggered (PRN ONLY) regimens present a particular challenge on our busy general
hospital wards and where possible the appropriate fixed dosing regimens should be used to
prevent unwanted escalation of withdrawal symptoms.
Symptom-triggered regimens should therefore only be considered where there is a need to
monitor the patient’s underlying physical health concerns very closely e.g. reduced renal
function.
Chlordiazepoxide 20mg – 30mg PRN max 240mg / 24hrs (or an equivalent dose of alternative
Benzodiazepine) should be adequate in most cases.
Nutritional support to prevent Wernicke’s Encephalopathy with Pabrinex 2 x pair TDS 72hrs is also
required.
Nursing Staff to complete CIWA-AR, Assessment and Measurement of Alcohol Withdrawal tool to
determine the severity of withdrawal symptoms, frequency of observations and need for PRN
medication. [APPENDIX 2]
Page 20 of 41
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8.5
v.3
Jac Electronic Prescribing
In order to optimise patient care and minimise the risks associated with inadequate prescribing
there are two fixed dosing alcohol detox regimens available to prescribers using JAC.
Selecting “ALCOHOL” as the drug to be prescribed, a choice of three detox regimens is offered:

LOW DOSE SADQ 15-25

HIGH DOSE SADQ 30-49

VERY HIGH DOSE SADQ 40-60
By selecting the preferred regimen and clicking “YES” on the following confirmation screens the
appropriate fixed dose reducing regimen of Chlordiazepoxide, PRN Chlordiazepoxide and
Pabrinex is rapidly prescribed.
No fixed dose reducing regimen for Lorazepam is available. For patients with impaired hepatic or
renal function individualised regimes at equivalent doses will be required. [sec 8.9]
8.6
Delirium Tremens
Management of Delirium Tremens requires specialist intervention including the administration of IV
Benzodiazepines , advice from DANS or senior members of the medical team is advised.
The most complex form of acute alcohol withdrawal, occurring in about 5% of cases, Delirium
Tremens and recurrent alcohol withdrawal seizures are medical emergencies and treatment is
administered in the patient’s best interest to prevent rapid deterioration.
Attention should be paid to the Mental Capacity Act 2005 policy PAT/PA 19 and Restrictive Practice
Policy PAT/PS 15.
The purpose of treatment is to make the patient calm and relaxed, over sedation or “flattening” the
patient should be avoided.
The drug recommendations listed are for adult patients with Deilrium Tremens, the BNF does not
provide alternative regimens, in the elderly or patients with hepatic or renal impairment dose
titration should be made in response to clinical symptoms.

Oral Lorazepam as the first-line treatment 1– 2 mg in response to CIWAR-AR.

If symptoms persist or oral medication is declined, consider parenteral Benzodiazepines.

Titrate IV / IM Lorazepam up to 0.5 to 1mgs every thirty minutes in response to CIWAR-AR
Page 21 of 41
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v.3

Titrate IV Diazepam emulsion 5 - 10 mgs every 30 – 60 minutes [should be given at a rate of not
more than 5mgs per minute into a large vein]. Try to avoid IM administration due to
unpredictable absorption.

Baseline physical observations prior to IV drug administration to be repeated every 15 mins
for the first hour and half hourly for the next four hours. PAT/PS 15 – Restrictive Practice
Policy.

Nursing staff to complete CIWA-AR scores and repeat observations as directed

If using more than one type of Benzodiazepine, approximate equivalent doses are as follows:
Chlordiazepoxide 15mg , Diazepam 5mg , Lorazepam 500mcg Nitrazepam 5mg
Temazepam 10mg

WARNING: Up to 50% of patients with DTs have a secondary infection, gastro-intestinal
bleeding or evidence of trauma especially head injury. These conditions must be actively
excluded or treated if present.

RAPID TRANQUILLISATION – should not be regarded as a primary treatment technique,
intervention should be reasonable and proportionate to the identified risk.

Rapid tranquillisation or urgent sedation should only be used in situations requiring the
rapid control of agitation, aggression or excitement in adult’s psychiatric / acute hospital
inpatients where de-escalation techniques alone have not proved sufficient.

Suggested further reading: NICE (2005) VIOLENCE: The short-term management of
disturbed / violent behaviour in psychiatric in-patient settings and emergency
departments. Clinical Guideline 25
8.7
Hallucination
Auditory, visual or tactile hallucinations can develop within 24 hours and can last for a further 24 –
48 hours.
They can occur in patients with an otherwise clear sensorium.

Severe psychotic symptoms may be managed by the addition of Haloperidol 1 to 5mgs 2-3
times a day.

Adequate treatment with benzodiazepines to manage the underlying withdrawal is the
priority.
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8.8 Seizures
Seizures can occur 6 – 48 hours after alcohol cessation. Patients with a history of seizure are more
likely if there is a history of previous withdrawal seizure or epilepsy.

Alcohol withdrawal seizures are usually self-limiting; however if a patient develops prolonged or
recurrent seizures, intravenous Lorazepam [2mgs] is effective in terminating seizures and
preventing re-occurrence, and may be less of a respiratory depressant than diazepam.

Some units advocate Carbimazepine [100mg – 200mg twice daily] loading in patients with
untreated epilepsy: those with a history of more than 2 seizures during previous withdrawal episodes
 previous seizures despite adequate diazepam loading.

Those who have a seizure for the first time should be investigated to rule out an organic disease
or structural legion [Maudsley, 2005]:- subdural etc.
 require a CT scan - brain
 rule out head injury - subdural haemorrhage even if the patient is known to have alcohol
withdrawal seizures

There is little or no evidence to support conventional anti-epileptics in either the treatment
of prophylaxis of alcohol withdrawal seizures. [Maudsely, 2005].
8.9
Liver Disease
For patients with grossly deranged Liver Function suggestive of acute alcoholic hepatitis or
decompensated alcohol related liver disease first line treatment with Chlordiazepoxide is not
recommended due to impaired metabolism and accumulation.

Lorazepam is the preferred Benzodiazepine and should be prescribed at an equivalent
dose to Chlordiazepoxide

Lorazepam 1mg = Chlordiazepoxide 30mg

Where there is evidence of hepatic encephalopathy symptom triggered dosing with
Lorazepam is favoured over fixed dosing regimens.

When treatment with regular Lorazepam has been insufficient to control severe alcohol
withdrawal symptoms, use of symptom triggered dosing of Chlordiazepoxide is required.
Please read pharmokinetics information provided.

DANS and Gastroenterology advice must be sought.
Page 23 of 41
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Drug Pharmokinetics
Lorazepam is rapidly absorbed after oral administration, with mean peak plasma concentrations
of free Lorazepam at 2 hours (range between 1-6 hours). Following intravenous administration,
peak plasma levels are reached within minutes, whereas following administration by the
intramuscular route, peak plasma levels occur between 60 to 90 minutes. After sublingual
administration, peak plasma levels occur at 60 minutes. By the intramuscular route, the
absorption half-life values of Lorazepam average 12 and 19 minutes, whereas by the oral route,
there is an additional lag period averaging 15 and 17 minutes. Bioavailability was shown to be
identical by all routes of administration. Lorazepam is rapidly conjugated to a glucuronide which
has no demonstrable psychopharmacological activity and is excreted mainly in the urine. Very
small amounts of other metabolites and their conjugates have been isolated from urine and
plasma. Serum half-life of Lorazepam ranges between 12 to 15 hours, while that of the conjugate
varied between 16 to 20 hours. Most of the drug (88%) is excreted in the urine, with 75%
excreted as the glucuronide. At the clinically relevant concentrations, approximately 85% of
Lorazepam is bound to plasma proteins. (Pfizer)
Chlordiazepoxide is well absorbed with peak blood levels being achieved one or two hours after
administration. Rate of absorption is age-related and tends to be delayed in the elderly. After
absorption it is highly bound to plasma proteins. Serum half life Chlordiazepoxide is 6-30 hours.
Steady state levels are usually reached within 3 days. Chlordiazepoxide is extensively
metabolised in the liver by hepatic microsomal enzymes and exhibits capacity limited, protein
binding sensitive, hepatic clearance. Pharmacologically active metabolites of Chlordiazepoxide
include desmethylchlordiazepoxide, demoxepam, desmethyldiazepam and oxazepam. The active
metabolite desmethylchlordiazepoxide has an accumulation half-life of 10-18 hours and
Demoxepam has an accumulation half-life of approximately 21-78 hours. Steady state levels of
these active metabolites are reached after 10-15 days with metabolite concentrations which are
similar to those of the parent drug.
8.10
Nursing Management
The safe management of acute withdrawal is best achieved through proactive rather than reactive
management. Steps such as;



early identification through screening and triage assessment
Close monitoring of physical observations using CIWAr tool
Appropriate use of routine and as required medication
Can prevent the escalation of simple withdrawal to complex withdrawal.
The following general measures should be put in place [Ghodse, 2002]:





Ensure adequate levels of medical and nursing staff
Treat the patient in a well lit area away from other patients
Keep external stimuli, especially noise, to a minimum
Use a friendly, understanding but firm approach
Be aware of the possibility of withdrawal fits
Page 24 of 41
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v.3
Where a patient presents with challenging behaviour i.e. delirium and this represents a risk to
the patient or others it may be necessary to intervene in order to maintain patient safety.
Measures to maintain patient safety such as physical or chemical restraint should be at a level
proportionate to the level of risk in keeping with PAT/PS 15 Restrictive Practice Policy: Clinical
holding, restraint and restriction.
9.
DISCHARGE PLANNING
The decision when to discharge patients receiving alcohol detoxification is one that requires
careful consideration. Discharge planning should adhere to the Trust guidelines contained within
PAT/PA 3 - Discharge of Patients from Hospital Policy.
There are several common scenarios which might arise.
9.1
Self Discharge
Where a patient wishes to self discharge their Mental Capacity, as per the Mental Capacity Act
2005 – Policy for Staff (PAT/PA 19) must be established.
Patients experiencing complex alcohol withdrawal such as delirium, hallucination or delusions,
Wernicke’s Encephalopathy, MAY lack capacity and MAY require intervention to maintain their
safety and wellbeing.
Alternatively, patients experiencing uncomplicated withdrawal symptoms such as tremors,
sweats, pyrexia, tachycardia (albeit intensely) MAY their retain capacity.
Where patients are deemed to have capacity and wish to self discharge WPR10390A – release
from responsibility for discharge must be completed.
No Take home medication for detoxification is to be issued.
9.2
Non Compliance with Detox
Despite their good intentions and our best efforts some patients will continue to drink alcohol
whilst receiving alcohol detox. This represents a significant risk due to the mixing of
Benzodiazepines and alcohol.
if MEDICALLY FIT and patient safe to do so:




Assess patient capacity, document accordingly
Ensure no complex symptoms present – i.e. seizure , delirium
Inform patient that combining alcohol with detox medication is harmful and could result
in death. Document accordingly.
Discharge without Take Home Detox medications
Page 25 of 41
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

v.3
Document patient given advice to seek planned treatment from local Community Alcohol
Team
Document patient given advice that - acute withdrawal MAY occur and COULD result in
seizure IF alcohol ceased abruptly, continue drinking alcohol AND reduce intake slowly.
Where the patient is MEDICALLY UNFIT for discharge:





9.3
Assess capacity, document accordingly.
Inform patient that combining alcohol with detox medication is harmful and could result
in death. Document accordingly.
Discontinue routine dosing of detox medication.
Continue PRN only symptomatic relief of withdrawal symptoms in response to CIWA
score.
Continue routine vitamin supplementation i.e. Pabrinex / oral Thiamine
Patient Declines Detox Opportunity
Sometimes patients are admitted to hospital who are physically dependent on alcohol and
experience withdrawal symptoms whilst with us, BUT do not want to stop drinking upon
discharge.
IF medically fit AND safe to do so






9.4
Detox Completed – Medically Fit



9.5
Assess capacity, document accordingly.
Ensure no complex symptoms present – i.e. seizure , delirium
Discharge without Take Home Detox medications
Document patient given advice to seek planned treatment from local Community Alcohol
Team
Document patient given advice that acute withdrawal MAY occur and COULD result in
seizure IF alcohol ceased abruptly, continue drinking alcohol AND reduce intake slowly.
Explain benefits and offer oral Thiamine
Prescription for 28 days oral Thiamine
Advice / Referral regarding local community alcohol services
Liaison with existing community services i.e. Drug and Alcohol, Community Mental Health
Team.
Incomplete Detox – Medically Fit
Where possible the opportunity to fully complete detox in hospital should be provided, however,
for some patients the opportunity to complete detox at home is possible with careful planning
and consideration.
Page 26 of 41
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v.3
Where local pathways exist these should be adhered to:
Bassetlaw Drug & Alcohol Service – A protocol for Completion of Hospital Initiated Alcohol
Detoxification
Where there are no local pathways in place i.e. Doncaster OR the patient declines input from the
community alcohol team for a continuation of detox, discharge can still take place with take
home detox medication providing a RISK ASSESSMENT has been completed.
The Risk Assessment should consider the following:
Suitable
Simple withdrawal – tremors, sweats
Asymptomatic – receiving routine meds
Supported – non drinking family
members, spouse
Mental health stable ,Non suicidal
Non drug user, ex drug user, stable
community drug treatment
Planning abstinence – choosing to be
alcohol free
Absence Neurological symptoms –
completed initial Pabrinex 2 x pairs TDS
for 72hrs
Contra-indication
Complex withdrawal – delirium,
hallucination, paranoid delusions
Symptomatic – requiring PRN in past
24hrs
Unsupported – living alone, NFA
Mental health unstable, Suicidal,
admitted with overdose
Chaotic Drug use – heroin , methadone,
benzodiazepines
Controlled drinking – risk mixing alcohol
and medication
Neurological Symptoms – Seizures
(whilst receiving Detox) , Wernicke’s
Encephalopathy
NOTE
There is no given Day or Dose at which discharge becomes possible, each case is different and
the decision to discharge should be a purely clinical one and not be driven by external factors
such as demand for beds.
Where Community Mental Health or Drug services are involved liaison with the patients named
worker is advised.
9.6
Maximum Take Home Doses
Clear instructions of day / dose and timing medications should be clearly documented in the
Medication Changes section of the Discharge Letter to assist the patient.
For suitable, well supported patients engaged with Community Alcohol Services
Chlordiazepoxide 15mg QDS (0800/1200/1800/2200hr)
Chlordiazepoxide 10mg QDS (0800/1200/1800/2200hr)
Chlordiazepoxide 10mg BD (0800/1800hr)
Chlordiazepoxide 10 OD (0800hr)
Page 27 of 41
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For suitable patients not engaged with Community Alcohol Services
Chlordiazepoxide 10mg QDS (0800/1200/1800/2200hr)
Chlordiazepoxide 10mg BD (0800/1800hr)
Chlordiazepoxide 10 OD (0800hr)
No PRN doses to be given as Take home.
The decision to discharge with medication exceeding the above guidelines should only be
taken following a joint review by the responsible Consultant and DANS.C
10.
WERNICKE’S ENCEPHALOPATHY
An acute life-threatening neurological syndrome consisting of confusion, apathy, dullness,
delirium, palsies of the ocular muscles, nystagmus, disturbances in equilibrium, and ataxia.
Its most common cause in industrialized countries is thiamine deficiency associated with
alcoholism.
If not treated immediately with thiamine, the patient is likely to progress to an amnesic state
and may even die.
10.1
Background
Thiamine plays a role in metabolizing glucose to produce energy for the brain. An absence of
thiamine therefore results in an inadequate supply of energy to the brain, particularly the
hypothalamus and mammillary bodies.
Heavy alcohol use increases the demand for and interferes with the metabolism of thiamine, so
even in cases where patients are eating a balanced diet while drinking heavily, the metabolic
problem persists because most of the thiamine is not absorbed.
10.2
Diagnosis
A diagnosis of Wernicke’s encephalopathy can be difficult to establish as the triad of classic
symptoms is seldom present;
Signs
Incidence
Mental changes
82%
Ataxia
23%
Eye signs
29%
Classic Triad
10%
Page 28 of 41
PAT/T 25
v.3
A high index of suspicion is therefore needed and diagnosis should be based on the presence of
any one of following signs [Chick 2000, Cook 2000, Morgan 1998].

•
•
•
•
•
•
Acute confusion
Decreases consciousness level including unconsciousness/coma
Memory disturbance
Ataxia/unsteadiness
Ophthalmoplegia
Nystagmus
Unexplained hypotension with hypothermia
Mental changes such as confusion, drowsiness, obtundation (slowness of response), pre-coma
and coma maybe the only signs of Wernicke’s encephalopathy [Cook, 1998].
These mental changes are non-specific and may be attributed to head injury, intoxication or
alcohol withdrawal resulting in a missed diagnosis of Wernicke’s.
10.3
Treatment
Parenteral thiamine (Pabrinex) followed by oral thiamine should be given to harmful or
dependent drinkers:

If they are malnourished or at risk of malnourishment OR

If they have decompensated liver disease
AND

Attend an emergency department OR

Are admitted to hospital with an acute illness or injury
SYMPTOMATIC WERNICKE’S

IV Pabrinex 2 x ampoule pairs TDS for 5 days AND continue until there is no further
improvement in clinical symptoms
HIGH RISK OF / ASYMPTOMATIC WERNICKE’S

IV Pabrinex 2 x ampoule pairs TDS for 3 days followed by 1 x ampoule pair daily for a
further 5 days
Offer prophylactic oral thiamine to harmful or dependent drinkers:

If they are malnourished or at risk of malnourishment OR

If they have decompensated liver disease OR

If they are in acute alcohol withdrawal OR

Before and during a planned medically assisted alcohol withdrawal

Thiamine 100mg TDS
NICE (2014)
Page 29 of 41
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v.3
Note – Oral treatment alone does not create sufficiently high concentrations of Thiamine
within the blood stream to bring about passive diffusion and is therefore ineffective at
preventing harm to patients who are at HIGH RISK of developing Wernicke’s .
11.
TRAINING/ SUPPORT
DANS service to provide ongoing education and training via:






12.
Rolling Preceptorship package
Rolling CQC package
DANS update days
Individual ward teaching sessions
1:1 support
Student shadowing
MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT
What is being Monitored
Who will carry out
the Monitoring
How often
FAST – ED completion
ED sister
annual
FAST – combined risk
assessment
CIWAR completion
annual
Detox regimen choices
Ward sisters /
DANS
Ward sisters /
DANS
DANS
Discharge planning
DANS
annual
13.
annual
annual
How Reviewed/
Where Reported to
Emergency care governance
group
Emergency care governance
group
Emergency care governance
group
Emergency care governance
group
Emergency care governance
group
DEFINITIONS
ABV% - Alcohol By Volume
AUDIT – Alcohol Use Disorders Identification Test
BD – Twice daily
CG – Clinical Guideline
CIWA-AR – Clinical Institute Withdrawal Assessment – Alcohol Revised
DANS – Drug and Alcohol Nurse Specialist
DTs – Delirium Tremens
FAST – Fast Alcohol Screening Test
FAST ED – Fast Alcohol Screening Test Emergency Department
IPOC – Integrated Pathway of Care
Page 30 of 41
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NICE – National Institute for Clinical Excellence
NTA – National Treatment Agency
OD – Once daily
PAT – Paddington Alcohol Test
PHG – Public Health Guideline
PRN – As the occasion arises
SADQ – Severity of Alcohol Dependence Questionnaire
TDS – Three times daily
QDS – Four times daily
14.
EQUALITY IMPACT ASSESSMENT
An Equality Impact Assessment (EIA) has been conducted on this procedural document in line
with the principles of the Equality Analysis Policy (CORP/EMP 27) and the Fair Treatment for All
Policy (CORP/EMP 4).
The purpose of the EIA is to minimise and if possible remove any disproportionate impact on
employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No
detriment was identified. [APPENDIX 6]
15.
ASSOCIATED TRUST PROCEDURAL DOCUMENTS
Discharge of Patients from Hospital Policy – PAT/PA 3
Equality Analysis Policy – CORP/EMP 27
Mental Capacity Act 2005 – Policy and Guidance - PAT/PA 19
Privacy and Dignity Policy - PAT/PA 28
Restrictive Practice Policy: Clinical holding, restraint and restriction – PAT/PS 15
16. REFERENCES
Adinoff B [1988] et al. Medical toxicology; 3: 172 -196
Armstong D, Phillips T, [2002] Management of Patients with Alcohol Problems on a
Psychiatric Ward, Hull & East Riding Community NHS Trust.
Chick J [2000]. Hosp Pharm; 7: 251 – 254
Cook, CCH et al [1998] Alcohol Alcohol, 33(4): 317-336
Cook, CCH et al, [2000] Alcohol Alcohol, 35[Supplement 1]: 19-20
CRAG/SCOTMEG [1991] Working Group on Mental Illness. The Management of Alcohol
Withdrawal & delirium tremens: A good practice statement. Final Report. London: HMSO, 1994
Page 31 of 41
PAT/T 25
v.3
Department of Health, (2005) National Treatment Agency for Substance Misuse Models of care
for alcohol misusers. Consultation document. London
Department of Health, NICE (2005) VIOLENCE: The short-term management of disturbed /
violent behaviour in psychiatric in-patient settings and emergency departments. Clinical
Guideline 25
Drug and Therapeutics Bulletin, [1991], 29(18): 69-71
Erwin WE et al, [1998], 91(5): 425-432
Ghodse, H. (Ed) (1998). Department of Psychiatry of Addictive Behaviour: Handbook. London
University.
Hall W et al. [1997], Lancet, 349: 1897-1900
HMSO (2012) The Government’s Alcohol Strategy
NICE (2010) CG100 Alcohol Use Disorders – Diagnosis and clinical management of alcohol –
related physical complications
NICE (2010) PHG24 Alcohol Use Disorders – preventing the development of hazardous and
harmful drinking
NICE (2011) CG115 Alcohol Use Disorders – Diagnosis, assessment and management of harmful
drinking and alcohol dependence.
NICE (2014) NICE Pathways – Wernicke’s encephalopathy and Wernicke-Korsakoff syndrome.
Maudsley, [2005] Prescribing Guidelines, Martin Dunitz, London
Morgan, MY et al editors. [1998] Alcohol and Health. Medical Council on Alcoholism London.
Royal College of Physicians (2001) A Report of the Working Party of the Royal College of
Physicians: Alcohol – can the NHS afford it? Health Development Agency. London.
Rubino, FA. [1992] Psychiatry Clinical, North America, 15(2): 359-372
Stribler H. (1991), Carbohydrate-deficient transferrin in serum: a new marker of potentially
harmful alcohol consumption reviewed. Clinical Chemistry. 37: 2029 -37
Turner A et al [1989] J General Intern Medicine, 4: 423-444
Wallace P (2001) Patients with alcohol problems – simple questioning is the key to effective
identification and management. British journal of General Practice 51: 172-3
Page 32 of 41
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APPENDIX 1 – COMBINED RISK SCREENING AND ASSESSMENT
DOCUMENT (FAST)
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APPENDIX 2 – CIWA-AR
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APPENDIX 3 - AUDIT
SCORING SYSTEM
AUDIT
0
1
2
3
4
Never
Monthly or less
2-4 times per
month
2-4 times per
week
4+ times
per week
How many units of alcohol do you drink
on a typical day when you are
drinking?
1-2
3-4
5-6
7-9
10+
How often have you had 6 or more
units if female, or 8 or more if male, on
a single occasion in the last year?
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year, have
you found that you were not able to
stop drinking once you had started?
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year, have
you failed to do what was normally
expected from you because of your
drinking?
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have
you needed an alcoholic drink in the
morning to get yourself going after a
heavy drinking session?
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year, have
you had a feeling of guilt or remorse
after drinking?
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year, have
you been unable to remember what
happened the night before because
you had been drinking?
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Have you or somebody else been
injured as a result of your drinking?
No
Yes, but not in
the last year
Yes, during
the last
year
Has a relative or friend, doctor or other
health worker been concerned about
your drinking or suggested that you cut
down?
No
Yes, but not in
the last year
Yes, during
the last
year
How often do you have a drink
containing alcohol?
SCORING SYSTEM 0 - 7 LOWER RISK, 8 – 15 INCREASING RISK, 16 – 19 HIGHER RISK, 20+
POSSIBLE DEPENDENCE
Page 36 of 41
Your Total
Score
Your
Score
PAT/T 25
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APPENDIX 4 - SADQ
The following questions cover a wide range of topics to do with drinking. Please read
each one carefully and answer without thinking too much about the exact meaning.
Answer all questions in relation to your recent drinking
Question
0
1
Never Sometimes
3
Often
Do you find it difficult getting the thought
of alcohol out of your mind?
Is getting drunk more important than
your next meal?
Do you plan your day so you know you
will be able to drink?
Do you start drinking in the morning and
continue drinking right through the
afternoon into the evening?
Do you drink as much as you can
without considering what you have to do
the next day?
Knowing that many of your problems
may be caused by alcohol, do you still
drink too much?
Do you find that once you have had one
drink you have to have another?
Do you need an alcoholic drink to get
yourself going in the morning?
Do you notice a definite tremor in your
hands in the morning?
When you have been drinking, do you
go out of your way to avoid people?
Do you see things and later realise they
were not real?
Do you find that you have gaps in your
memory or are unable to remember
recent events?
Do you vomit following a drinking
session?
Do you deliberately control your
drinking by giving up for days or weeks
at a time?
Scoring
Scores below 15 indicates Mild Dependency
15-30 indicates Moderate Dependency
30-40 indicates Severe Dependency
40-60 indicates Very Severe Dependency DISCHARGE PLANNI
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4
Nearly always
PAT/T 25
APPENDIX 5 – FAST ED
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PAT/T 25
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PAT/T 25
ISCHG
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PAT/T 25
APPENDIX 6 – EQUALITY IMPACT ASSESSMENT PART 1 INITIAL SCREENING
Service/Function/Policy/
Project/Strategy
CSU/Executive Directorate and
Department
Assessor (s)
New or Existing
Service or Policy?
Date of Assessment
PAT/T 25 v.3
ALL
SHANE PEAGRAM
EXISTING POLICY
15/9/14
1) Who is responsible for this policy? Name of CSU/Directorate - SHANE PEAGRAM – DRUG AND ALCOHOL NURSE SPECIALIST
2) Describe the purpose of the service / function / policy / project/ strategy
The identification and management of persons with alcohol issues whilst inpatients within the hospital setting.
3) Are there any associated objectives? NICE (2010) CG100 Alcohol Use Disorders – Diagnosis and clinical management of alcohol – related physical
complications. NICE (2011) CG115 Alcohol Use Disorders – Diagnosis, assessment and management of harmful drinking and alcohol dependence. And should
be read in conjunction with NICE (2010) PHG24 Alcohol Use Disorders – preventing the development of hazardous and harmful drinking
4) What factors contribute or detract from achieving intended outcomes? – Staff Compliance with the Policy
5) Does the policy have an impact in terms of age, race, disability, gender, gender reassignment, sexual orientation, marriage/civil partnership,
maternity/pregnancy and religion/belief? Details: [see Equality Impact Assessment Guidance] - No
 If yes, please describe current or planned activities to address the impact [e.g. Monitoring, consultation] –N/A
6) Is there any scope for new measures which would promote equality? [any actions to be taken] No
7) Are any of the following groups adversely affected by the policy?
Protected Characteristics
Affected?
Impact
a) Age
No
b) Disability
No
c) Gender
No
d) Gender Reassignment
No
e) Marriage/Civil Partnership
No
f) Maternity/Pregnancy
No
g) Race
No
h) Religion/Belief
No
i) Sexual Orientation
No
8) Provide the Equality Rating of the service / function /policy / project / strategy – tick outcome box
Outcome 1 
Outcome 2
Outcome 3
Outcome 4
*If you have rated the policy as having an outcome of 2, 3 or 4, it is necessary to carry out a detailed assessment and complete a Detailed Equality Analysis form in Appendix 4
Date for next review: April 2017
Checked by:
Shane Peagram
Date: 15.9.14
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