when to d/c alcohol detox pts

[meerkat111]

Considering this can be done on outpt basis, if a homeless guy/gal gets admitted for alcohol withdrawl, when would it be the best time to dc him or her?

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[IM2GI]

Before they have a chance to start withdrawing.

 

[gutonc]

Considering this can be done on outpt basis, if a homeless guy/gal gets admitted for alcohol withdrawl, when would it be the best time to dc him or her?

From the ED, as soon as you hear about them, before they even get assigned a bed.

 

[gutonc]

I can't speak for @IM2GI, but I'm not kidding.

If they're there because they want to get into an inpatient treatment bed (LOL) then, OK, admit, get 'em through the acute w/d and find placement for them (LOLOLOL). If they're there because the PoPo or EMS picked 'em up passed out on the sidewalk and they have no intention of quitting, let 'em go so they can get their next drink before the s*** hits the fan and you're stuck with them for a week.

 

[CatFactorial]

I can't speak for @IM2GI, but I'm not kidding.

If they're there because they want to get into an inpatient treatment bed (LOL) then, OK, admit, get 'em through the acute w/d and find placement for them (LOLOLOL). If they're there because the PoPo or EMS picked 'em up passed out on the sidewalk and they have no intention of quitting, let 'em go so they can get their next drink before the s*** hits the fan and you're stuck with them for a week.

It's especially nice when you have a particularly theatric EMS pick-up with grandiose intentions to quit. Like the one I had to admit, convince not to leave, file AMA paperwork, readmit a few hours later, be subject to the ceremonial pouring-out-of-vodka-handle, get admitted to psych for inpatient detox, find out that he eloped while transferring.

 

[rokshana]

I can't speak for @IM2GI, but I'm not kidding.

If they're there because they want to get into an inpatient treatment bed (LOL) then, OK, admit, get 'em through the acute w/d and find placement for them (LOLOLOL). If they're there because the PoPo or EMS picked 'em up passed out on the sidewalk and they have no intention of quitting, let 'em go so they can get their next drink before the s*** hits the fan and you're stuck with them for a week.

This.

 

[IM2GI]

I can't speak for @IM2GI, but I'm not kidding.

If they're there because they want to get into an inpatient treatment bed (LOL) then, OK, admit, get 'em through the acute w/d and find placement for them (LOLOLOL). If they're there because the PoPo or EMS picked 'em up passed out on the sidewalk and they have no intention of quitting, let 'em go so they can get their next drink before the s*** hits the fan and you're stuck with them for a week.

Not kidding at all. It is a waste of everyone's time and puts the patient at risk if they are just going to be discharged and start drinking again.

 

[AlmadeDr]

Whenever we had one admitted that was the first question: are you going to stop/cut down/get help. If yes we mobilize services and start tapering benzos. If not, discharge ASAP.

Sometimes you get stuck for a few days because they are not tolerating PO for some reason or mental status too poor to guarantee they will be able to make it to the nearest liquor store before they start seizing/hallucinating

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[Raryn]

The big problem is if they happen to go through detox while actually sick.

So you're stuck keeping them for their pneumonia treatment, then keep them an extra week while getting them through detox.

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That said, my favorite solution was one that some of our surgeons would do: Give them beer with each meal to avoid detox. That is, they had to be admitted for their whatever operation, but the surgical team didn't want to deal with detox. So they ordered the kitchen to give the pt 2 bud lights with each meal. Never done it myself though.

 

[FutureInternist]

The big problem is if they happen to go through detox while actually sick.

So you're stuck keeping them for their pneumonia treatment, then keep them an extra week while getting them through detox.

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That said, my favorite solution was one that some of our surgeons would do: Give them beer with each meal to avoid detox. That is, they had to be admitted for their whatever operation, but the surgical team didn't want to deal with detox. So they ordered the kitchen to give the pt 2 bud lights with each meal. Never done it myself though.

I am a hospitalist and do this a lot.

Ask them their preferred poision then order Spiritus fermenti in Epic, set it and forget it .

They also have the option of having family bringing in their preferred drink, give to pharmacy who then dispenses it like a non-formulary home med.

Why go through the hassle of a detox when they have no intention of quitting.

I had many arguments with one ICU attending in Residency since he would never order it - Why should we promote a patient's bad habits, FutureInternist?

Well it's better than potentially intubating them for DTs. The day he switched off the service, we would start all the pts that needed one, on it and DC CIWA

 

[doctorbeastmode]

Not to add on the pile, but CIWA protocols never seem to even work that well. Everyone has had a patient go into the DTs while on CIWA, while most alcoholics don't go into withdrawal if they have access to alcohol.

So yeah - not even for cynical reasons, the correct time is in the ED.


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[CatFactorial]

Not to add on the pile, but CIWA protocols never seem to even work that well. Everyone has had a patient go into the DTs while on CIWA, while most alcoholics don't go into withdrawal if they have access to alcohol.

So yeah - not even for cynical reasons, the correct time is in the ED.


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CIWA protocols are dumb. One cannot trust nurses to decide when is appropriate to give benzos. Such as a cirrhotic patient with asterixis who gets 2 mg of lorazepam, intubation, and a trip to the MICU.

 

[clausewitz2]

Yeah, CIWA or a CWAS is a terrible idea unless you have nursing staff who are well-trained and experienced in using it. If someone has a dodgy respiratory status, I understand why you would not leap to scheduled benzos, but why exactly are you all not doing this for run-of-the-mill folks who are detoxing?

I feel like writing for two Bud Lights and calling it a day is just incredibly dangerous. The kinds of folks who start to have medically significant withdrawal behind two days in the hospital are also often the folks who are going through a fifth of spirits daily (or vastly more). Why on earth would you not just schedule Valium?

Genuine question from ignorance, I guess, but from the psych side, I have a hard time seeing what you are accomplishing by using commercial alcoholic beverages to prevent GABAergic withdrawal apart from making it a) harder to titrate the necessary dosing and b) having a bit of a laugh.

I need no convincing that it is stupid to try and detox someone who is uninterested in cutting back on their drinking, but that is kind of a separate issue.

 

[Gastrapathy]

They will titrate their own booze just fine. Your benzos not so much. If they aren't quitting, why mess with their system.

 

[Siggy]

At my hospital... the time to discharge is the second the psychiatrist drops the psych hold... because the police and some of the ED staff seems to think that if an alcoholic keeps drinking then they're a danger to themselves.