Patients in detox -- we need dedicated units!!

sistasoul · Feb 8, 2010

I absolutely agree with you. I also work on a neuro floor. It seems my floor gets all of the ETOH, drug abusers, etc., etc. These are the most TIME CONSUMING, NEEDY AND DEMANDING patients I have ever dealt with. Most have psych issues to begin with and that is why they are usually abusing substances. These people do not belong on a medsurge floor but on a psych unit where they have specially trained staff to deal with them. I have always thought there should be a special unit for these people but because this is probably an expensive concept it will never come to light. We as nurses are asked to keep these patients safe without adequate staffing and the same old CIWA and COW protocols that don't work in every situation.

SoundofMusic · Feb 8, 2010

Thanks, Sistasoul. You get the problem. No, CIWA does not always work. And I for one am NOT the pharmacological expert on what every pt might need in detox. That really would be the MD -- but it's not always the case. And at our hospital, the pt has to detox w/ us first before he/she is "accepted" into psych or CATS. Gimme a break.

Yeah -- some poor 80 year old stroke patient should really be sharing the floor or a room w/ some naked fool running down the halls. This is a travesty.

sistasoul · Feb 8, 2010

Thanks, Sistasoul. You get the problem. No, CIWA does not always work. And I for one am NOT the pharmacological expert on what every pt might need in detox. That really would be the MD -- but it's not always the case. And at our hospital, the pt has to detox w/ us first before he/she is "accepted" into psych or CATS. Gimme a break.
Yeah -- some poor 80 year old stroke patient should really be sharing the floor or a room w/ some naked fool running down the halls. This is a travesty.

I agree. I think the detox centers should be set up with trained nurses/staff so they can be shipped from the ER directly to the detox center. Let them detox there so they don't scare the living daylights out of my sweet little old ladies and gents. I for one find them the hardest patients to deal with. I don't even mind dealing with my peeps with alzheimers/dementia but detoxing patients are a whole other animal.

By the way, you are funny. The part about the naked fool cracked me up because I have seen it myself.

Bill E. Rubin · Feb 8, 2010

We deal with a fair number of detox pts as well on my unit (general medicine). Nobody enjoys it, but what can you do? Could you imagine the fun nurse managers would have trying to recruit nurses to work on such a unit as you describe? :lol2:

Our unit is conveniently located down the hall from the inpatient psych unit at our hospital... but the fact is that the patients need to be cleared medically before any psychiatric treatment can occur. This is also true of failed suicide attempts, of which we get a moderate number.

HM2VikingRN, RN · Feb 8, 2010

At the very least you should have protocols for the usage of restraints, 1-1's and antipsychotic medications. Ativan alone won't cut it for the management of symptoms of agitated psychosis. (Look up the B52 for one possible combination to discuss with your providers.) Here is a protocol at http://www.google.com/url?sa=t&source=web&ct=res&cd=8&ved=0CGsQFjAH&url=http%3A%2F%2Fwww.lsuhsc.edu%2Fhcsd%2Fcmo%2Fhcet%2Fbehav_health%2FGriffies%2520Emergency%2520Psychiatry%2520update.ppt&ei=bshvS8W6BI_-nAfFqYypBg&usg=AFQjCNFZ4aUXiZgV56jLLeBAE79yfG9bjw&sig2=g-2otGj6BVr7A93WMxOltg for discussion.

Along with a dedicated subunit for management of agitated patients. (Basically its an area with doors that can be locked to reduce stimulation for agitated patients. Its not a seclusion room just a dedicated part of the milieu for managing agitation.)

Have you tried consulting with the hospital safety committee? Tried to get psychiatric coverage for the unit?

Sugarcoma, RN · Feb 8, 2010

Warning: long vent follows!

I could not agree with you more! Heres the best part, I work in a facility WITH a dedicated detox unit. Unfortunately we CANNOT send our actively withdrawing to them until they are at least detox day 3! Not day 3 when they start, but at least three days after the start of active withdrawl. The reason.....they are not medically stable and thus need to be on a med surg floor.

So we get to break out the morphine and the ativan and occasionally if we have a really progressive doc on call the Haldol, set the bed alarms and proceed to spend the whole night restarting the ngs, foleys, and IV's they keep pulling. Running down the hall every 5 seconds when the bed alarms go off. Listen to them scream, threaten, run naked, and everything else and calling the docs every 10 minutes to beg for restraints or sitters.

And if we are lucky enough to get a sitter it comes out of our matrix. So when we have 2 techs for our 24 heavy post op pts with JP's, ostomy, penroses, chest tubes, foleys and NG's galore; blood sugars, turn q2, EVERYONE needs assistance to the bathroom, q4 vitals, and lab draws, actively sundowning and dementia: ONE tech gets to do all that while the other has to sit. Then you get to spend the night fielding phone calls from bed desk and the nursing manager "We need to get that sitter d/ced. Do everything you can to get that sitter dc/ed."

It is ridiculous! It is totally unsafe. You spend your whole night dealing with these fools while your other 6-7 patients who need you get ignored. You don't get to eat, pee, or sit down. You get to spend the night dodging their stool, spit, and whatever else they can find to throw at you. Your almost guaranteed a trip to another fall prevention inservice because they always fall.

And the best part is getting called into the managers office two days later to be told:

"your patient in this room had a 8/10 pain rating for 45 minutes before you got them anything. That is not in alignment with our core values."

Or patient X called patient relations on you because you forgot to bring them an extra blanket.

Or you did not complete the vaccine assessment on your new admit and the nurse who followed you complained!

I HATE detox patients!

BluegrassRN · Feb 8, 2010

I love detoxers. We have great protocols and responsive docs. I rarely need a sitter for one, but we have them available if we do.

Sounds like your facility does not have adequate protocols or nursing administration. If your doc isn't doing the right thing, why was the chief of medical staff not notified? If your guy is running naked up the halls, a danger to all, why wasn't he if 5 points with a sitter? Where was your floor director in all this?

Don't let your floor manager chide you. Tell him/her what was lacking and that the protocols need to be reevaluated and updated. Ask her guidance as to what you are to do next time. WRITE IT UP as an incident report. That way, the hospital gets your version on the permanent record AND someone besides your director see is. No upper-level administrator wants to know that there was a naked, violent detoxer running around the unit, and that the doc refused to order anything more than ativan for him.

questionsforall · Feb 8, 2010

Could you imagine the fun nurse managers would have trying to recruit nurses to work on such a unit as you describe?

Count me out.:)

elkpark · Feb 8, 2010

Our unit is conveniently located down the hall from the inpatient psych unit at our hospital... but the fact is that the patients need to be cleared medically before any psychiatric treatment can occur. This is also true of failed suicide attempts, of which we get a moderate number.

ITA -- acute withdrawal is a medical issue, not a psychiatric issue. I used to work psychiatric consultation-liaison in a big urban teaching hospital, where all the acute detox people were admitted to medical beds, and we (the PCL team, supervised by a BC addictionologist) followed those folks for their detox. We managed detox aggressively, and, during the years I was there, we never had situations like the ones being described here (and restraints were v. rarely needed). On the other hand, we didn't admit for PCP (or any stimulants or hallucinogens) detox/withdrawal -- only ETOH, benzos, and, sometimes (depending on how big a user the person was), opiates. Our addictionologist's position was that there was no medical indication for admitting for stimulant or hallucinogen withdrawal, and the medical staff (inc. the ED docs) were fine with that. Our system there seemed to work pretty well.

HouTx, BSN, MSN, EdD · Feb 8, 2010

I feel your pain - detox is really a very unpredictable situation. Lots of potential and very real medical problems, but all wrapped up in a nutcase.

I fondly recall a doc (many years ago) who had it all figured out. He would simply admint them to ICU, intubated, sedated & paralyzed for a few days until they became manageable. Some were even dialyzed to speed up the process. I don't actually recall what the admitting diagnoses were - usually some type of 'drug reaction' or r/o meningitis, stroke, or whatever. By the time the patient was allowed to wake & taken off the vent, they were 'rested, tanned & ready' to head back out for more party drugs. This doc was very popular with the more affluent crowd who could afford his unique 'treatment protocol'.

BTW, this doc was actually a gastroenterologist.... LOL.

SoundofMusic · Feb 8, 2010

i fondly recall a doc (many years ago) who had it all figured out. he would simply admint them to icu, intubated, sedated & paralyzed for a few days until they became manageable. some were even dialyzed to speed up the process. i don't actually recall what the admitting diagnoses were - usually some type of 'drug reaction' or r/o meningitis, stroke, or whatever. by the time the patient was allowed to wake & taken off the vent, they were 'rested, tanned & ready' to head back out for more party drugs. this doc was very popular with the more affluent crowd who could afford his unique 'treatment protocol'.

and you see -- this is what our nice old doctor was trying to do yesterday -- was to make this suggestion, but my floor managers would not have it. they felt he should be on our floor for his treatment and that it was our job to prevent him from going to the icu.

our ciwa protocol was not touching this guy. he was a danger to me and to others yet we were in this predicament. i had taken care of him the day before with no huge issues -- it was only at change of shift on the first day that he began to talk about wanting to leave and at that point we started thinking about a sitter -- yet my manager was chiding me for not rating him high enough the day before for a sitter. how could i have scored him for a sitter if he was not exhibiting any symptoms of wanting to leave??

so it's not like we didn't have sitters or we didn't have a protocol in place. it was that i supposedly was not assessing him correctly which i felt was unfair. he was not a problem until later in the day on the 2nd day.

i have used protocols successfully before w/ etoh detoxers -- but this was a different animal. there has just got to be a better way.