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Changing futures: premature discharges of alcohol or opioid detoxification in-patients, service improvement

  • Mark Parry (a1), Nicholas Woodthorpe (a2) and Priyanthi Gunawardena (a3)
Abstract
Aims and method

We retrospectively audited premature discharges of in-patients undergoing alcohol or opioid detoxification. Recommendations for good practice aimed at reducing premature discharge rates were implemented, following which a prospective audit was completed.

Results

The retrospective phase of the audit cycle showed a premature discharge rate of 30.8%, compared with a rate of 13.2% for the prospective phase. The difference in these rates is both clinically and statistically significant at the 5% level, with Fisher's exact test producing a two-sided P = 0.0119.

Clinical implications

Implementing good practice guidelines improved outcomes, with more patients successfully completing detoxifications and a more effective use of resources.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Mark Parry (mark.parry@berkshire.nhs.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Specialist Clinical Addiction Network (SCAN). Scan Consensus Project: Inpatient Treatment of Drug and Alcohol Misusers in the National Health Service. SCAN, 2006.
2 Balogh, R, Bond, S. Completing the audit cycle: the outcomes of audits in mental health services. Int J Qual Health Care 2001; 13: 135–42.
3 Martinez-Raga, J, Marshall, EJ, Keaney, F, Ball, D, Strang, J. Unplanned versus planned discharges from in-patient alcohol detoxification: retrospective analysis of 470 first-episode admissions. Alcohol Alcohol 2002; 37: 277–81.
4 Scherbaum, N, Heppekausen, K, Rist, F. Is premature termination of opiate detoxification due to intensive withdrawal or craving? Fortschr Neurol Psychiatr 2004; 72: 1420.
5 Gossling, HW, Gunkel, S, Schneider, U, Melles, W. Frequency and causes of premature termination (drop-out) during in-patient opiate detoxification. Fortschr Neurol Psychiatr 2001; 69: 474–81.
6 Gossop, M. Drug Addiction and Its Treatment. Oxford University Press, 2003.
7 Day, E. Opiate Detoxification in an Inpatient Setting. National Treatment Agency for Substance Misuse, 2005.
8 Rüesch, P, Hättenschwiler, J. Consequences of relapse and treatment drop-out in patient drug detoxification: a one-month follow-up study. Schweiz Arch Neurol Psychiatr 2002; 153: 238–44.
9 Tobin, M, Chen, L. Initiation of quality improvement activities in mental health services. J Qual Clin Practice 1999; 19: 111–6.
10 Nalpas, B, Combescure, C, Pierre, B, Ledent, T, Gillet, C, Playoust, D, et al. Financial costs of alcoholism treatment programs: a longitudinal and comparative evaluation among four specialized centers. Alcohol Clin Exp Res 2003; 27: 51–6.
11 Reoux, JP, Miller, K. Routine hospital alcohol detoxification practice compared to symptom triggered management with an objective withdrawal scale (CIWA-Ar). Am J Addict 2000; 9: 135–44.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
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Changing futures: premature discharges of alcohol or opioid detoxification in-patients, service improvement

  • Mark Parry (a1), Nicholas Woodthorpe (a2) and Priyanthi Gunawardena (a3)
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eLetters

Care and More Care

Mark S Parry, Consultant Psychiatrist
12 July 2010

In his response (1) to our article (2), Adwani underlines the importance of relieving withdrawal symptoms during detoxification. Delaysin administering medication are certainly a potent cause of patient dissatisfaction, and conversely prompt relief of symptoms is greatly appreciated by patients. Support from a Link worker involves training wardstaff so that they gain skill at assessing symptoms and using medications. The professional competence that results has important consequences. The approach to patients undergoing detoxification improves and this is perceived by the patients themselves leading to a better experience for ward staff. This can result in a" virtuous cycle" where improved performance on the part of staff leads to better patient satisfaction with treatment leading in turn to a more positive perceptionof such patients which results in better outcomes. A more skilful approach to and treatment of patients does not eliminates every problem, but it certainly reduces them. A skilful approach also involves managing expectations of the treatment process and here admission pre-visits are a vital ingredient. Patients can meet staff and start the process of adjusting to the psychiatric ward by gaining a more accurate perception ofit before they are admitted.

Many of our patients have stated that their experience on the ward has been positive, not least because they have been able to provide support to some of the non-detoxification patients on the ward which has improved their sense of self-esteem and self-efficacy. This last point wefeel, chimes in well with Adwani's questioning of segregation of patient groups on the basis of prejudice.

As well as skilled care during detoxification, proper assessment andpreparation of patients before admission and aftercare following dischargeare further key elements to successful outcomes.

1. Adwani A ‘Drugs or more drugs’ e- letter The Psychiatrist 21st June 20102. Parry M, Woodthorpe N, and Gunawardena P. (2010) Changing futures: premature discharges of alcohol or opioid detoxification in-patients, service improvement The Psychiatrist (2010) 34: 200-203
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Conflict of interest: None Declared

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Drugs or more drugs

Andrew Al-Adwani, Consultant psychiatrist
21 June 2010

The substantial improvement in drop-out rates achieved with an enhanced menu of inpatient interventions by Parry et al(1)is laudible. However, it would be disingenuous to pretend that alcohol and substance misusers, when on general adult psychiatry wards, are treated without prejudice by both staff and fellow patients. Occasionally punitive elements in treatment regimes become evident, such as withholding medications for longer than necessary. This is not surprising when one considers that about 40-50% (2)of this group of patients are comorbid for personality disorder, themselves an alienating group of conditions. The combination could be described as an attenuated form of malignant alienation (3) and therefore a recipe for poor outcomes.

Having worked in a similarly organised service for a number of years,the element of care that seemed to have the most marked effect on improveddetoxification completion rates was the addition of a link worker attending, liaising with and advising the wards. The drop-out rate was very low. The link worker plays an extremely important role in maintaining a therapeutic environment by instilling optimism and making staff feel well supported and safe. Parry et al acknowledge the value of the link worker, but there is a particular aspect of this arrangement that is not fully covered. Patients being regularly assessed by a link worker will, in most cases, have a baseline detoxification regime with additional medication given promptly on the basis of withdrawal symptom scores. This gives each patient a highly individualised course of treatment and in a number of cases might have resulted in the prospective group receiving higher overall amounts of substitute/symptomatic medication. The regular additionof extra medication might also have increased hospital stays.

There is though a more interesting question that arises from this work that relates to the advantages, if any, of being treated in a specialist unit. Looked at more broadly the question is whether segregation, as a response to prejudice, has ever benefited any particulargroup.

1. Parry M, Woodthorpe N, and Gunawardena P. (2010) Changing futures:premature discharges of alcohol or opioid detoxification in-patients, service improvement The Psychiatrist (2010) 34: 200-203

2. Bowden-Jones, O., Iqbal, M. Z., Tyrer, P., et al (2004) Prevalenceof personality disorder in alcohol and drug services and associated co-morbidity. Addiction, 99,1306 -1314

3. Watts, D. & Morgan, G. (1994) Malignant alienation. Dangers for patients who arehard to like. British Journal of Psychiatry, 164, 11–15.
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Conflict of interest: None Declared

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