Policy Number / LCH-173

This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form.

Part A – Information about this Document

Policy Name / Intoxicated Patient Guidelines
Policy Type / Board Approved (Trust-wide) ☐ / Trust-wide ☐ / Divisional / Team / Locality ☒
Action / No
Change / ☐ / Minor
Change / ☐ / Major
Change / ☐ / New
Policy / ☒ / No Longer
Needed / ☐
Approval / As Mersey Care’s Executive Director / Lead for this document, I confirm that this document:
a)complies with the latest statutory / regulatory requirements,
b)complies with the latest national guidance,
c)has been updated to reflect the requirements of clinicians and officers, and
d)has been updated to reflect any local contractual requirements
Signature: / Date:

Part B – Changes in Terminology(used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only)

Terminology used in this Document / New terminology when reading this Document

Part C – Additional Information Added(to be used with ‘Major Changes’ only)

Section /
Paragraph No / Outline of the information that has been added to this document – especially where it may change what staff need to do

Part D – Rationale(to be used with ‘New Policy’ & ‘Policy No Longer Required’ only)

Please explain why this new document needs to be adopted or why this document is no longer required

Part E – Oversight Arrangements (to be used with ‘New Policy’ only)

Accountable Director
Recommending Committee
Approving Committee
Next Review Date

LCH Policy Alignment Process – Form 1

SUPPORTING STATEMENTS

This document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS
All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including:
  • being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult;
  • knowing how to deal with a disclosure or allegation of child / adult abuse;
  • undertaking training as appropriate for their role and keeping themselves updated;
  • being aware of and following the local policies and procedures they need to follow if they have a child / adult concern;
  • ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust’s safeguarding team;
  • participating in multi-agency working to safeguard the child or adult (if appropriate to your role);
  • ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;
  • ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS
Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.
The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.
Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.
Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

Title

/ Managing patients/visitors who appear intoxicated within the Liverpool Community Health Trust Premises
Guideline reference
number /
173
Aim and purpose of guideline / To support staff in appropriately managing patients and visitors who appear intoxicated within Liverpool Community Health premises
Author / Nurse Clinician Ambulatory Care and Diagnostics Clinical Nurse Manager Walk In Centre
Type / New Guideline

Reviewed Guideline

Review date /

December 2019

Person/group accountable for review /

Clinical Standards Group

Type of evidence base used / C: Evidence which includes published and/or unpublished studies and expert opinion

Issue date

/ January 2018
Authorised by Clinical Standards Group /
19th December 2017
Impact Assessment Undertaken / Yesdate when Evidence
undertakencollated

No

Version Control 4

Key individuals involved in developing the document

Name / Designation
Margaret Carran / Nurse clinician
Susan Lamb / Clinical nurse manager

This document was circulated to the following individuals for consultation

Name / Designation
Ann Twist / Clinical nurse manager
Liz Norris / Clinical nurse manager
Rachael Stannaway / Acting Clinical nurse manager
Gaynor Rumsby / Practice Development mentor WIC’s

This document should be read in conjunction with the following documents:

  • LCH Health and Safety Policy 2017
  • LCH Security Policy 2017
  • LCH Managing Violence and Abusive Incidents Policy 2017
  • Policy 137 Safeguarding Supervision
  • Policy 78 Safeguarding Children Policy and Procedure
  • WIC Triage Policy

Contents

Page
1 / Purpose of the guideline / 4
2 / Scope of the guideline / 4
3 / Background – the intoxicated patient / 4
4 / Definitions / 5
5 / Conditions that can mask or mimic intoxication / 6
6 / Signs of potential threatening behaviour / 6
7 / Managing aggressive behaviour (non-physical and physical) / 7
8 / Assessment of the patient / 9
9 / Action to be taken when violent or abusive incident has occurred / 10
10 / Monitoring tool / 11
11 / Contributors and peer review / 11
12 / Distribution list and dissemination / 11
13 / References / 11
Appendix 1: Algorithm for the patient or visitor who appears to be intoxicated / 12
1 Purpose of the Guideline

This guidance is to support staff working within LiverpoolCommunity Health ServicesCentres in the management of patients and visitors who appear to be intoxicated and may become abusive.

2 Scope of guidelines

All staff working within the LiverpoolCommunity Health premisesthat have direct patient/publiccontact.

3 Background-The Intoxicated patient

In 2011/12, there were an estimated 1,220,300 admissions related to alcohol consumption where an alcohol-related disease, injury or condition was the primary reason for hospital admission or a secondary diagnosis. This is an increase of 4% on the 2010/11 figure (1,168,300) and more than twice as many as in 2002/03 (510,700). Costs to the NHS of alcohol misuse shows that it costs £3.5 billion every year, which is equal to £120 for every taxpayer. These estimates are presented in the government paper published in 2013, Public Health Responsibility Deal. Mortality rates attributable to alcohol have doubled with 1 in 5 male inpatients having an alcohol related problem.

The problem of managing alcohol relatedbehavior is increasing within the Liverpool Community Health Services Trust premises and there is a need for guidance to enable staff to provide appropriate care and support forall patients, staff, carers and members of the public who may be presenting at the same time as other patients/visitors who appear to be under the influence of alcohol.

In some, but not all cases whena patient appears to be intoxicated there is the possibility of this encounter becoming aggressive.Aggression creates instability in the environment, impacts on patient care outcomes and leads to increased levels of stress in staff. Regular exposure to aggression in the workplace can have detrimental effects on the health professionals’ wellbeing. NHS premises are gateways to care and can be a crowded environment. Therefore, it is essential that all health professionals are confident and well prepared to manage patients who appear to be intoxicated and who may have the potential to be aggressive.

4 Definitions

Intoxicated

A state in which a person's normal capacity to act or reason is inhibited by alcohol or drugs.

Physical Assault

The intentional application of force by the person to another, without lawful justification, resulting in physical injury or personal discomfort.

Deliberate Assault

An act of violence or aggression has been committed with intent. There is no underlying medical condition linked to their behaviour.

Non Physical Assault

The use of inappropriate words or behaviour causing distress and/orconstituting harassment.

Clinical Assault

A person who is at the time of the incident, lacking in mental capacity due to their mental health status, medical condition, general health or exceptional circumstances i.e. if a patient has dementia, is confused, has a UTI/ chest infection which may affect behaviour or has had a stroke and is unaware of their actions.

Wernicke's encephalopathy

A serious neurological condition (Mental confusion/ataxia) caused by thiamine deficiency characteristically associated with chronic alcoholism

5 Conditions that can mask or mimic intoxication

All staff need to be alert to the fact that some conditions can mask or mimic intoxication. Staff should consider this in the first instance.

Conditions include, but are not exclusively listed below:

• Infections

• Respiratory disease, hypoxia

• Head injury

• Acute psychotic state

• Diabetes, hypoglycaemia

• Epilepsy (temporal lobe)

• Drug toxicity

• Meningitis

• Withdrawalfor alcohol or drugs

• Wernicke's Encephalopathy

6Signs of potentially threatening behaviour

  • increased restlessness, anxiety, pacing, excitability
  • angry facial expressions
  • refusal to communicate, withdrawal from others
  • poor concentration, unclear thinking
  • raised voice, shouting and/or erratic movements
  • violent delusions or hallucinations
  • verbal threats or gestures
  • known violent behaviour in the past

7 Managing aggressive behaviour (non-physical and physical)

The risk of violence and aggression towards staff should be assessed at reception for each patient and reviewed periodically dependent on their behaviour. If security services are present on site at the time they should be informed and assist the practitioners with their attempt at assessment by ensuring patient and staff safety at all times.

Supportive care will most often prevent an patientappearing to be intoxicated from becoming upset or frightened and/or disrupting other patients, staff and visitors. When dealing with suchpatients/visitors, it is recommended that the following principles are adhered to:

  • Approach the patient in a friendly and respectful manner. Patronising and authoritarian attitudes can often evoke anger and make patients aggressive. This is a common response to threats to our dignity and self-respect
  • Be aware of other causes of apparent intoxication observing for any obvious signs i.e. head injury
  • If friends who also appear to be intoxicated accompany the patient, assess if it is prudent and safe to ask them to wait outside
  • The security/receptionist must let the practitioner know they are dealing with a potentially intoxicatedpatient
  • Provide the patient with a seat in an uncluttered, quiet part of the waiting room if possible
  • Try and prioritise the patient in order to facilitate a speedy discharge/referral. Thereceptionist may discuss this with shift leader
  • Staff must introduce themselves, giving their name and role
  • The practitioner should undertake a risk assessment in the first instance to establish if two practitioners are required for the consultation or if security services should be asked to be present nearby
  • Within Walk in Centres the Practitioner must follow the triageor initial assessment policy (may be bypassed if taken straight into consultation) asking specific questions about the presenting illness or injury
  • The practitioner should undertake a full assessment in order to elicit information. If the individual is intoxicated they may not be as compliant with the assessment
  • When possible, postpone questions or procedures that antagonise the patient
  • Do undertake vital signs/observation to exclude any underlying problems
  • If the patient consents, a capillary blood glucose test will exclude the possibility of diabetes-related hypoglycaemia and in order to detect it as a complication of alcohol abuse especially in children
  • The practitioner shouldavoid information overload and repeat information if necessary
  • When instructing the patient or seeking cooperation, give clear, concrete instructions. If necessary, guide them to and from triage /initial assessment /consulting rooms and taxis, andhand them paperwork or personal belongings etc.

Reduce the possibility of accidents, anger and/or aggression by:

  • Use space for self-protection, e.g. do not crowd the patient trying to ensure that you are able to leave the room if necessary
  • The practitioner should speak in acalm and reassuring way
  • The practitioner shoulduse the patient's name when speaking to him or her
  • Do not challenge or threaten the patient by tone of voice, eyes or body language
  • Let the patient air their feelings, and acknowledge them
  • Determine the source of the patient's anger and if possible, remove the source
  • Staff must ensure that the patients staff and visitors are safe at all times this may include requesting support from the police if the patient becomes so aggressive that they becomes a danger to themselves or others

8 Assessment of Patients

Pro-active assessment of patients is required, particularly when there is a suspicion that an individual may be violent and/or aggressive towards staff or other patients or present a risk to themselves.

Where present,security should observe as the patient books in. This may include an accompanying visitor within the waiting area who also appears intoxicated.

The security / receptionist staff should make theshift leader (and triage nurse)aware of any patient/persons presenting within the centre that they feel may give cause for concern due to possibleintoxication.

Risk assessment should be undertaken by the Shift leader on duty at the time the person presents and take in to account any previous alerts.

If apatient presents as incoherent, disoriented or drowsy; this should be treated as a head injury until proven otherwise, urgent assessment and referral may be necessary.

Assessment of patients/person presenting with what may be thought of as intoxication is covered in Appendix A.

Safeguarding teams should be consulted for advice on further management /referral of all patients who are deemed to be at risk to themselves and or others. If child presents due to alcohol abuse or with a hypoglycaemic episode due to alcohol abuse this incident should be referred to Child Protection Facilitator

9Action to be taken when a violent or abusive incident has occurred

  • Raise alert as soon as possible either using the “green button” on screen if near a computer logged on OR using the panic buttons in the rooms
  • Line manager must ensure that the employee is safe after the incident
  • Incident to be reported through Datix
  • Line manager to carry out a risk assessment in accordance with the Risk Assessment Policy and must include any previous history, current situation and any threats of future behaviour
  • Outcomes to be fed back to staff as part of the risk assessment process
  • Periodically review the risks
  • Line manager to ensure all staff have attended Conflict Resolution training

In line with the specific legal remedies outlined below, a range of measures can be taken by Liverpool Community Health (LCH) depending on the severity of the assault, which will assist in the management of unacceptable behaviour by seeking to reduce the risk and demonstrate acceptable standards of behaviour. These may include:

  • Verbal warning
  • Acknowledgement of Responsibilities Agreement (ARA)
  • Written warnings withholding treatment
  • The use of secure environments
  • MDT’s and potential escalation to High Risk persons Register (HRPR) referral process
  • Civil injunction and Anti-Social Behaviour Orders (ASBO) Criminal prosecution

Where necessary, the Police should be contacted, as soon as is practicable, by the person subject to the assault, or by their manager or a relevant colleague. The seriousness of the incident should be taken into account when deciding whether the Police should be involved.

Further detail may be found in

  • LCH Managing Violence and Abusive Incidents Policy 2017
  • LCH Risk Assessment Policy
  • LCH Lone Worker Policy

10Monitoring tool

This guideline will be monitored throughDATIX forms and team meetings/briefings

11Contributors and Peer Review

The guidelines have been through a peer review involving front line staff and Clinical Nurse Managers and approved by the Deputy Director of Nursing

12Distribution list and dissemination

This policy will be disseminated to the relevant front line staff through the team meetings, Team Brief, the Trust Intranet, LCH weekly and PS Magazine

13References

  • Clark et al 2003 Work with patients who are intoxicated. A competency within the Community Services Training Package
  • Public Health Responsibility Deal, Department of Health, 2013. Available at:
  • AlcoholConcern promoting health ;Improving lives 2015
  • The Victorian Alcohol and Other Drugs Workforce Development Strategy Training Resource. Page 27 CHCAOD6B. Work with patients who are intoxicated

Appendix A