Download Procedure for Alcohol and Drugs Intoxication

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
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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
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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