We are currently attempting to place a standard for client who present for emergency psychiatric assessment of clients with chronic alcoholism. There is concerns about letting the clients blood alcohol levels drop to normal sobriety which could induce withdrawal versus when clients are clinically sober and can participate in safe assessment and informed consent?
Hello Richard,
(Standard blood alcohol level-there is no standard, but admission to mental health facilities usually use 1.0)
Since the level of incapacitation varies even with the same blood alcohol content, the practise is variable, as well. Certainly, a mental health assessment will have limited validity/ reliability of information, if performed with a still intoxicated person. Due to the disinhibiting effect of alcohol, patients seem much more likely to be suicidal or aggressive then.
What might be of use to you is a systematic withdrawal protocol, in which you assess and treat withdrawal symptoms systematically (usually with temoporary benzodiazepines). Example: CIWA ( Clinical Institute Withdrawal Assessment) . Of course, supervised withdrawal is much safer, not just for accuracy of assessment, but also monitoring for medical complications such as seizures.
Regards
I don't think it's necessary or useful to incorporate blood alcohol levels into your decision-making tool because the correlation between blood levels and symptoms of intoxication / withdrawal is likely to be highly variable across patients. What is more important is whether patients are sufficiently cooperative and have capacity to consent to undergo assessment. This is a purely clinical decision. Typically mental health symptoms improve rapidly with detoxification for most patients, so a diagnostic psychiatric assessment is best deferred for at least several days, and preferably a few weeks. The main priorities for assessment at the first point of contact are risk and determining where patients should be managed- ie home vs social detox centre vs hospital.
Thanks for the input. James do you know of any research supporting clinical decision versus Blood alcohol level for Emergency Department patients and decisions to evaluate upon clinical sobriety versus Blood Alcohol
I'm sorry I don't have a specific citation on this, and it probably requires a brief review of the literature. O'Connor & Schottenfeld's article "Patients with alcohol problems" in the New England Journal Feb 1998 is now an old article but is still a very good overview of the management of patients with alcohol problems.
I think you need to more clearly define what is the purpose of the emergency psychiatric assessment you mention, because this will determine when it is best performed. If the assessment is designed to identify and manage risks related to acute intoxication, then it should occur immediately; if the goal is to identify and manage patients at risk of withdrawal-related complications (seizures and delirium) then it should occur slightly later but still within 12 to 24 hours (see Marc Schuckit's recent article on Delirium Tremens). If the goal is to identify psychiatric conditions likely to require separate treatment, then that should occur once withdrawal symptoms have subsided (see my recent paper in J Affective Disorders).
James, thanks so much. The purpose of the exam is to determine whether or not the clients are in need of inpatient or outpatient treatment. The clients present to the ED in Criris are we must assess whether or not they need inpatient treatment for crisis. Many of our clients present with dual diagnosis. We usually wait until the BAC is around .13 but at times clients may be clinically sober much earlier. We are trying to set policy about when these clients can be evalauted. Many times the evaluation is not for detox but to determine inpatient treatment versus release from the ED and OP referral. Thanks so much for you help. Could you send me a link or copy of the paper you mentioned.