PRN for ETOH withdrawal day of discharge

[sassyann85]

Just wanted some input...

There was a patient who came in and was on the alcohol withdrawal protocol, with symptom triggered PRN ativan ordered. He wasn't on a scheduled taper. No hx of seizures or anything. He was more or less scoring high enough on with withdrawal scale to get the PRN because of anxiety and some agitation (not because of sweating, tremors, etc). He decided to sign a 72 hour notice to sign himself out after being there a day or so. On the morning he ultimately ended up getting discharged (the RNS didn't know he would be getting discharged this day because the Dr. hadn't come in to round yet), he got a PRn Ativan for "withdrawal" (with his anxiety/agitation prompting the score to be high enough to trigger for a PRN ativan). He was a very anxious guy in general. He received this about 8am. When the Dr came in a few hours later, he talked to the patient and said he was going to discharge him. I mentioned to the Dr that the patient had received a PRN Ativan earlier that day, but the Dr was ok with discharging him. At the time he actually left the unit (a few hours after receiving the 8am ativan), he wasn't anxious, his vitals were fine, etc.

My question is, was it legitimate of the dr to discharge him despite the fact that he got a PRn for 'withdrawal' earlier that same day? The RNS do tend to be somewhat liberal with the PRN Ativan for withdrawal because the patients can be so anxious and agitated as they are giving up their substance of choice (alcohol). But I don't know if the Ativan would have been given if it was known he was getting discharged that day. Even though the pt didn't have tremors, visual disturbances, etc from withdrawal and mainly just had anxiety that allowed him to score high enough for the Ativan, I just wasn't sure if there could be an issue with the Dr. discharging this patient and if any liability could come on the nurse if there were any issues.

Thanks!

[elkpark]

I've never heard of there being any problems with the kind of scenario you describe. The physician felt he was safe for discharge. Lots of people are walking around on the streets, taking Ativan for a variety of reasons, without any difficulty. What, specifically, are you concerned about?

[sassyann85]

I was just thinking, if the patient received a med indicated for withdrawal several hours before discharge (even though the reason he scored 'high enough' on the withdrawal scale was due to anxiety/agitation) could someone say he was discharged while still going through acute alcohol withdrawal and the

Ramifications of that?

[Whispera, MSN, RN]

It sounds like he needed the ativan for his anxiety and agitation. While he was in the facility meds needed to be given if needed. I agree with elkpark--lots of people walk around with ativan on-board. The patient had decided he wanted to leave, and signed the papers. The doctor couldn't keep him there against his will.

[sassyann85]

He was not going to be given a script for ativan at discharge

[Sun0408, ASN, RN]

He was given Ativan to prevent DTs while in the hospital. Chances are once released he will drink as usual. What exactly are you having a issue with OP??

[Jules A, MSN]

I was also going to say he probably will drink after discharge. That said I will sometimes give a 1x dose of Librium on the morning of discharge if there is questionable chance of withdrawal including education that they absolutely shouldn't drink alcohol of course.

[elkpark]

Over the years, I've seen lots of people admitted for EtOH (or other substance) detox change their minds and sign themselves out AMA once they get uncomfortable from the withdrawal. Since they typically plan on relieving their distress by using again as soon as possible after they leave the hospital (I guarantee you they all know how to relieve sxs of withdrawal ...), there is not a lot of concern about potential ill effects of untreated withdrawal. In any case, if they have the mental capacity to make the decision to leave and are there voluntarily, there is no rationale for holding them against their will, and they are discharged. Happens every day.

[Farawyn]

No more Serax taper for ETOH? Or am I hopelessy out of touch?

[elkpark]

No more Serax taper for ETOH? Or am I hopelessy out of touch?

Benzo tapers (Serax or another benzo) still get used for EtOH detox -- or not, it depends on how much the person has been drinking, how long s/he has been drinking (recently), what kind of withdrawal hx the individual has (hx of DTs or w/d seizures) ...

[Meriwhen, ASN, BSN, MSN, RN]

I was just thinking, if the patient received a med indicated for withdrawal several hours before discharge (even though the reason he scored 'high enough' on the withdrawal scale was due to anxiety/agitation) could someone say he was discharged while still going through acute alcohol withdrawal and the

Ramifications of that?

If the patient wants to leave during the middle of ETOH withdrawal and there's no legal reason for the patient to be placed under a psychiatric hold (drug/ETOH withdrawal is not in itself a holdable reason), the patient is free to go. If, after having the risks of discharged explained to them and acknowledging they understand said risks, the patient still wishes to discharge, our liability ends--it's all on the patient now.

It's not uncommon for a patient, even an AMA, to get a good-bye dose of benzo before they leave. We will do this if we know the patient isn't driving themselves (they have a ride coming, or they're taking a taxi/public transport). If they are driving themselves, we will not administer a benzo in the last few hours before discharge.

You'd be surprised how many AMA discharges I get to deal with once the patient learns that it's not going to be a free-for-all with the medications they're going to get. Again, they're not (usually) holdable patients so there's nothing we can do.

[sassyann85]

thanks everyone for your responses!