Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Procedure for Patients Suspected of Alcohol and/or Drug Intoxication Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 1 of 12 DOCUMENT PROFILE and CONTROL. Purpose of the document: This procedure aims to highlight the key risks associated with cases of suspected alcohol and/or drug intoxication, and to compliment the national and LAS guidance already in place. Sponsor Department: Medical Directorate (previously Clinical Education & Standards) Author/Reviewer: Senior Clinical Advisor. To be reviewed by January 2019. Document Status: Final Amendment History Date *Version 07/02/17 2.2 30/01/17 2.1 22/12/16 1.9 20/09/16 1.8 14/09/16 1.7 14/09/16 13/09/16 30/08/16 05/07/16 1.6 1.5 1.4 1.3 Author/Contributor IG Manager Senior Clinical Advisor IG Manager Senior Clinical Advisor Assistant Medical Director IG Manager Senior Clinical Advisor Consultant Paramedic Acting Education Governance Manager Amendment Details Document Profile and Control update Minor changes required by PMAG Document Profile and Control update Statement to S.5.2.8 regarding capacity added Minor changes and comments Document Profile and Control update Implementation Plan added Amendments Update of documents / references to include Medical Directorate bulletin MD97. S5.3.6 „ambulance attendant‟ replaced by „most clinically qualified person. S5.3.8 additional information source changed to MD97, and patient positioning specifically referenced. S5.3.9 additional advice to use a PRF continuation sheet if necessary. Implementation plan; removal of „biannual‟. 17/05/15 1.2 Education Update of terminology and references. Governance Manager Inclusion of guidance for „Legal & Herbal + previous Highs‟ in Sections 1.1 & Appendix 1. contributions from Add new Section 4 - „Responsibilities‟. Senior Clinical Adviser Add new Section 5.4 – „Specialist to Medical Director & Resources for the Management of Deputy Medical Intoxicated Patients‟. Director. Removal of references to OP/020 (as topic now subsumed within OP/014). 11/03/09 1.1 CGC Minor – s.1.3 added „potentially harmful‟ ; recommendations s 1.4 (full JRCALC guidelines title); „compromise‟ replaced „‟impairment‟; references 23/02/09 0.6 Head of Records Minor - scope Management 12/02/09 0.5 Head of Records Minor- amended formatting, added scope Ref. OP045 Title: Procedure for Patients Suspected of Page 2 of Alcohol and or Drug Intoxication 12 Management Educational Minor – implementation plan Governance Manager 28/11/08 0.3 Head of Records Minor – made additional comments and Management 20/11/08 0.2 Records Manager Minor – amended formatting 11/11/08 0.1 Educational Major – First draft Governance Manager, Medical Director *Version Control Note: All documents in development are indicated by minor versions i.e. 0.1; 0.2 etc. The first version of a document to be approved for release is given major version 1.0. Upon review the first version of a revised document is given the designation 1.1, the second 1.2 etc. until the revised version is approved, whereupon it becomes version 2.0. The system continues in numerical order each me a document is reviewed and approved. 30/12/08 0.4 For Approval By: PMAG CGC Ratified by (If appropriate): Trust Board Published on: The Pulse (v2.2) The Pulse LAS Website (v2.2) Announced on: The RIB Date Approved 26/01/17 23/02/09 19/05/09 Date 07/01/17 01/05/09 07/01/17 Date 14/02/17 Equality Analysis completed on 13/09/16 Staffside reviewed on Version 2.0 1.0 1.1 By Governance Administrator Records Manager Governance Administrator By IG Manager Dept G&A GDU G&A Dept G&A By Medical Directorate By Links to Related documents or references providing additional information Ref. No. Title Version Royal College of Emergency Medicine (2015) Alcohol Toolkit National Institute for Health and Care Excellence (2011) Alcohol-use disorders: diagnosis and management AACE National Clinical Guidelines TP/003 Policy Statement of Duties to Patients OP/031 Policy for Consent to Examination or Treatment OP/014 Managing the Conveyance of Patients Policy & Procedure MD97 Important advice regarding positional and restraint asphyxia Document Status: This is a controlled record as are the document(s) to which it relates. Whilst all or any part of it may be printed, the electronic version maintained in P&P-File remains the controlled master copy. Any printed copies are not controlled nor substantive. Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 3 of 12 1. Introduction 1.1 The London Ambulance Service NHS Trust (LAS) receives many calls to patients with alcohol or drug intoxication. While alcohol is the most common of all such substances, there are a myriad of other drugs that are capable of causing harm to patients with potentially fatal consequences. This vast spectrum includes licit (legal) drugs obtained on prescription or „over the counter‟ sources, to illicit (illegal) substances that have been acquired unlawfully. Equally, staff should be aware of the increasing use of Novel Psychoactive Drugs commonly referred to as „Herbal Highs‟, which are discussed further in Appendix 1. 1.2 In responding to incidents involving drugs or alcohol, staff must remain mindful that not all cases of intoxication are intentional. There are a wide range of illnesses and/or situations where patients can inadvertently become involved in medication and dosing errors. Equally, drugs can be administered unknowingly to patients, with the „spiking‟ of alcoholic drinks of growing prominence. 1.3 Any drug when taken in excess must be viewed as potentially harmful, which clearly highlights the need for prompt and careful clinical assessment and management. The very nature of these substances can often create difficulties in making an accurate assessment of the patient. This may be exacerbated by the use of alcohol and the social environment in which the incident has occurred. 1.4 Considerable care must therefore be applied to the management of all cases of suspected alcohol and/or drug intoxication, with due regard to the vulnerability and significant risks associated with these patients. The attention of staff is drawn to the Association of Ambulance Chief Executives (AACE) National Clinical Guidelines, which contain comprehensive information relating to the management of overdose and poisoning, as well as the associated complications arising from reduced levels of consciousness and risk of airway compromise etc. 1.5 It is imperative that staff remain fully conversant with all teaching and reference material provided and/or endorsed by the LAS, so as to ensure that current best practice is reflected at all times. Staff should seek guidance from line managers or the Clinical Hub for any areas of doubt. 1.6 This procedure aims to highlight the key risks associated with cases of suspected alcohol and/or drug intoxication, and to compliment the national and LAS guidance already in place. Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 4 of 12 2. Scope 2.1 This procedure covers the awareness and management of risks relating to patients who are suspected of drug and/or alcohol intoxication. It applies toall LAS staff. 3. Objectives 3.1 To provide additional direction and guidance to staff in their management of patients suspected of alcohol and/or drug intoxication. 3.2 To assist in minimising the risks to patients and staff of misdiagnosis, and to emphasise the added vulnerability and dangers associated with alcohol and drug intoxication. 3.3 To reinforce the issues around primacy of clinical care, where other agencies, e.g., the police, may be present or required on scene. 4. Responsibilities 4.1 All members of staff who are involved in the care and management of patients suspected of alcohol and/or drug intoxication are responsible for complying with the guidance contained in this procedure. 4.2 Line managers and Clinical Team Leaders (CTLs) are responsible for overseeing compliance with this procedure within their respective areas of operation. They are also responsible for developing and monitoring specific action plans in response to identified problems and deficiencies. 4.3 The Clinical Hub is responsible for providing support to staff with patient related clinical problems. This includes any aspect of patient assessment or treatment, as well as queries relating to substances of misuse. 5. Procedure 5.1 Safety on Scene 5.1.1 As with all situations, the safety of staff is of paramount importance and Personal Protective Equipment (PPE) should be utilised as a matter of routine. In approaching patients suspected of alcohol and/or drug misuse, staff must remain mindful that such substances can cause the patient to adopt erratic and unpredictable behaviour which requires careful and sensitive management. As with other potentially difficult situations, a calm and professional approach invariably helps minimise the risk of a patient developing uncooperative and aggressive behaviour. Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 5 of 12 5.1.2 It is equally important to recognise the potential risks from family, friends and bystanders, who may also be suffering from similar effects of alcohol/drug misuse. This once again highlights the need to approach and manage the incident in a caring and non-judgemental manner, thereby reducing the risk of confrontation. 5.1.3 However, in situations where staff still consider themselves to be at risk, they must withdraw from the immediate environment and summon police assistance at the earliest opportunity. 5.2 Patient Management 5.2.1 While substances of misuse originate from wide and varied sources, the majority fall into one of two categories, i.e., Central Nervous System (CNS) depressants or stimulants. These are described in detail within the AACE National Clinical Guidelines – „Overdose and Poisoning‟ (Adults & Children), with which staff must be fully familiar. 5.2.2 As highlighted previously, the very nature of these substances can create difficulties in making an accurate assessment of the patient. Most CNS depressant drugs, e.g., alcohol, when taken in excess can severely impair all physical and mental functions, leaving the patient particularly susceptible to respiratory depression, decreased levels of consciousness and airway compromise. Equally, patients may be at increased risk of hypothermia, and hypoglycaemia. These impairments also place patients at greater risk of sustaining further injury or illness. 5.2.3 Misuse of stimulants such as cocaine has the same lethal potential, but patients may present with hyperactivity, agitation, delirium, tachycardia, sweating and dilated pupils. Hyperpyrexia can subsequently develop, leading to tremors and convulsions. Acute myocardial ischemia is a recognised complication of cocaine toxicity. 5.2.4 Many of the signs and symptoms of substance misuse have close similarities with those of other illness and injury. Conversely, drug or alcohol intoxication may mask signs and symptoms. This is further complicated where several different drugs types are involved, which invariably includes alcohol. Consequently, the ability to recognise and attribute these to any specific condition is difficult, particularly in the pre-hospital environment. 5.2.5 Therefore, while some signs of underlying illness or injury may be evident, it is rarely possible to exclude the risk of further injury or illness in the presence of intoxication.. The potential for misdiagnosis cannot be overestimated in this patient group, particularly in terms of head injuries or where other conditions such as hypoglycaemia may easily be confused or masked by substance misuse. Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 6 of 12 5.2.6 All procedures for assessing and managing patients with suspected drug and/or alcohol intoxication are detailed in the National Clinical Practice Guidelines. These are mirrored in clinical training programmes provided by the LAS. 5.2.7 It is essential that all staff remain current with the content of Guidelines, as well as with other bulletins and information provided by the LAS. Although key elements of patient assessment and management are generally reviewed as part of the Core Skills Refresher programme, staff with any queries or concerns should seek advice from their CTL, or management team. 5.2.8 Crews are also reminded that they can contact the Clinical Hub in Emergency Operations Centre (EOC) at any time. The Hub is staffed by experienced paramedics who have been trained to support staff with patient related clinical problems. These include any aspect of patient assessment or treatment, as well as queries relating to substances of misuse. Clinical Hub staff have access to Toxbase, the National Poison Information Service Database, so additional information can be sought as required. Patients who have taken an intentional overdose should ideally be transported to hospital or referred for further care due to the potential for further deterioration and subsequent episodes of selfharm. This applies regardless of toxicity levels. However staff must be cognisant of, and follow the LAS policy and procedure to be followed if the patient is deemed to have capacity, (OP 31 – Policy for Consent to Examination or Treatment). 5.3 The Role of the Police 5.3.1 In many cases of suspected alcohol and/or drug misuse, the police are already on scene and will provide support and assistance to crews as required. Alternatively, the police may arrive on scene as a result of the situation outlined in paragraph 5.1.3, or when requested by LAS staff in response to concerns over capacity in the event of the patient declining aid. (Please refer to OP/031 „Policy for Consent to Examination or Treatment‟ and OP/014 Managing the Conveyance of Patients Policy and Procedure). 5.3.2 Irrespective of the reason for the police attending scene, it must be emphasised that the most qualified member of LAS staff has overall responsibility for the patient‟s clinical management at all times. This remains the case even in circumstances where the police undertake physical restraint. If the patient has been deemed to be healthy and does not require LAS intervention, then the Police may continue to restrain a patient they wish to detain. 5.3.3 In the event of a patient requiring restraint, there is an absolute need for close liaison and teamwork. This would generally take the form of a dynamic risk assessment, where the care and continuing welfare of the Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 7 of 12 patient remains the key priority throughout. (Please also refer to the LAS policy on restraint – OP 72) 5.3.4 In the vast majority of cases requiring the actual or potential need for force or restraint, the patient will be conveyed to hospital by ambulance. The dynamic risk assessment will have identified the level of support required from police officers to ensure the safety of all concerned, as well as allowing the most clinically qualified member of LAS staff to continually monitor the patient‟s condition. (Please also refer to the LAS policy on restraint – OP 72) 5.3.5 The use of an ambulance should always be the preferred option for transporting patients in view of the availability and accessibility of monitoring equipment etc. Therefore, the use of a police vehicle should only be considered in the rare circumstances of the patient being deemed unsafe to convey by ambulance. 5.3.6 In these situations, it is imperative that the most clinically qualified member of staff travels in the police vehicle, together with appropriate equipment items from the ambulance to render care. The patient must in full view of the LAS member of staff at all times. The ambulance should follow closely behind, and be capable of being summoned to stop and provide additional equipment in the event of a sudden deterioration in the patient‟s condition. It is once again reiterated that the most clinically qualified person retains responsibility for the patient‟s clinical needs throughout the entire process. (Please also refer to the LAS policy on restraint – OP 72) 5.3.7 LAS OP/031 „Policy for Consent to Examination or Treatment‟ provides comprehensive guidance with regard to all aspects of capacity and consent. OP/014 „Managing the Conveyance of Patient Policy and Procedure‟ details the specific procedures agreed between the MPS and the LAS in the management and conveyance of patients. 5.3.8 In addition, the conditions of Positional Asphyxia and Acute Behavioural Disturbance have a particular relevance in the assessment and management of patients associated with alcohol and drug misuse. It is therefore imperative that all frontline staff have a thorough understanding of these two conditions, along with their recognition and prevention. Further information can be found in Medical Directorate bulletin MD97; „Important advice regarding positional and restraint asphyxia.‟ This identifies that no patient should be restrained and / or transported face down or in the prone position unless this is specifically indicated in a patient with maxillo-facial injuries where supine positioning leads to airway compromise. 5.3.9 As in all situations, the importance of recording and documenting all observations, decisions and actions taken cannot be overemphasised. Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 8 of 12 This includes noting the shoulder numbers of police, and/or the names and designation of other individuals involved. It is imperative that all such information is captured on the PRF, using a continuation sheet as necessary. 5.4 Specialist Resources for the Management of Intoxicated Patients 5.4.1 The impact of large numbers of intoxicated patients (especially if clustered in a small area or short timeframe) on the ambulance service and emergency departments is well recognised. It is essential that it is recognised that by nature of their intoxication, these are very vulnerable people, many of whom are under age. These patients are also very difficult to assess, and have a high risk of missed injury or illness and the potential for, subsequent assault and injury, including sexual assault. 5.4.2 The LAS supports the development and use of specialist services (both static and mobile) to manage these patients, with the provision that: There are robust operational and clinical governance arrangements. Facilities are resourced by a paramedic or other registered healthcare professional at all times. Patients undergo a thorough assessment by a trained clinician. A written record of the consultation (PRF) is produced, and that this includes regular observations. Treatment administered is in line with Trust and AACE National Clinical Guidelines. Patients are not held on-site beyond a reasonable length of time. Minors (persons aged 17 years or less) must be conveyed to an emergency department, as must patients with evidence of injury, preexisting medical conditions or concomitant drug use. 5.4.3 Clinical Guidelines for the Management of Intoxicated patients at NonEmergency Department Locations have been produced and must be adhered to by staff undertaking duties at such venues. Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 9 of 12 IMPLEMENTATION PLAN Intended Audience For all LAS Staff Dissemination Available to all staff via the Pulse Communications Revised Procedure to be announced in the RIB and a link provided to the document Training The topics highlighted in this policy are addressed in the core training programmes delivered by the Department of Clinical Education & Standards. Also use of Team Leader updates and Clinical Updates. Monitoring: Aspect to be monitored Frequency of monitoring AND Tool used 5.2 Patient management 5.3 The role of the police 5.3.8 use of restraint 5.4 Specialist Resources for the management of inrtoxicated persons 5.2 Patient Management & 5.3 The Role of the Police – Will be monitored through the use of the LAS CPI framework Ref. OP045 5.3.8 Will be monitored via the use of DATIX for each episode of restraint used (particularly if sedation has been used)5.4 Use of Specialist Resources – Will be monitored via the use of specific Event Individual/ team responsible for carrying out monitoring AND Committee/ group where results are reported Assistant Director of Operations for each area reports to the Quality Committee for 5.4 EPRR will report back via their Debriefing system to the reuisiste Group or Committee depending on the issue identified. This will normally be via the Operations Board Committee/ group responsible for monitoring outcomes/ recommendations How learning will take place Quality Committee (and Trust Board if required) Learning disseminat ed via various mechanism s including: Core Skills Refreshers, Medical Directorate Bulletins, Area Quality Meetings, Routine Information Bulletins, etc Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 10 of 12 Plans for large scale events / Mass Gatherings such as the London Marathon, New Year‟s Eve etc… where extra resources / provision is provided for this cohort of patients. Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 11 of 12 Appendix 1 A1 Novel psychoactive substances, including “Herbal Highs” / “Legal Highs” A1.1 The terms; “Herbal High” or “Legal High” are very misleading. Many of these drugs are neither herbal in origin, nor legal. They are often marketed as plant food, and their names are many and varied, as are their side effects, many of which can affect the cardiovascular and / or nervous system. A1.2 Given the nature of these substances, and their highly suspect composition/manufacturing process; the default position should be conveyance to an Emergency Department for further assessment and treatment. A1.3 Those with acute toxic effects should be managed symptomatically, and conveyed to an Emergency Department. Less acute physical or psychological problems should be assessed and managed as for any other users of psychoactive drugs. Some patients may present early with a temporary 'comedown' and low mood from recent drug use, and may just need reassurance, support and monitoring. A1.4 Other patients may have started to show signs of dependence and need specialist assessment, or present with physical or psychological symptoms that they believe may be linked to their drug use. In all such cases, appropriate diagnostic assessments are needed as per normal clinical practice. A1.5 Further advice can be sought from the Clinical Hub, which has access to Toxbase, the National Poison Information Service Database. Ref. OP045 Title: Procedure for Patients Suspected of Alcohol and or Drug Intoxication Page 12 of 12