sha-os-025a assisted self isolation tobacco and alcohol ......have you ever experienced previous...

COVID-19 PANDEMIC PRACTITIONER ORDER SET Assisted Self-Isolation Tobacco and Alcohol Use Disorder Withdrawal Prevention and Management

Patient’s name:

HSN:

DOB: dd/mm/yyyy

To complete the order form, fill in required blanks and check the appropriate boxes (). Pre-checked boxes () are initiated automatically. To delete orders, draw one line through the item and initial.

Allergies: See Regional Allergy / Intolerance Record OR: Patient Weight Kg Actual Estimated

Posted Initial

ORDERS AND SIGNATURE of 2

Date & Time Practitioner Signature:

Practitioner Name (printed):

Effective Date: July 28, 2020 SHA OS-025a Authorization: SHA Chief Medical Officer July 28, 2020 Send order set change requests to [email protected]

This order set is to be used in conjunction with SHA OS-025 Assisted Self-Isolation – Initiation Orders, and is to be used as an outpatient prescription to be filled at the patient’s community pharmacy. This order set is NOT intended for Inpatient or ER use.

TOBACCO USE DISORDER

Patient may smoke or vape in their room and/or balcony

AND/OR:

Nicotine Replacement Therapy

Dispense daily x days

Choose ONE of the following options:

Patient smokes less than 10 cigarettes per day: Nicotine Patch 7 mg daily

Patient smokes 10 - 20 cigarettes per day: Supply: Nicotine Patch 14 mg daily

Patient smokes 21 - 30 cigarettes per day: Nicotine Patch 21 mg daily

Patient smokes 31 - 40 cigarettes per day: Nicotine Patch 28 mg (21 mg +7 mg) daily

Patient smokes greater than 40 cigarettes per day: Nicotine Patch 42 mg (21 mg +21 mg) daily

AND:

Nicotine gum 2 mg pieces PRN (maximum of 10 pieces per day)

ALCOHOL USE DISORDER

Baseline CIWA-Ar score (see Appendix “A”):

PAWSS score (see Appendix “B”):

Patient is more suitable for supervised/inpatient withdrawal management if:

PAWSS greater than 4

CIWA-Ar greater than 20

Any history of alcohol withdrawal seizures, or delirium tremens

Any of fever, disorientation, drenching sweats, severe tachycardia, hypertension, pregnancy, concurrent substance use

Diastolic blood pressure greater than 100 mmHg, Heart Rate greater than 120 bpm or irregular heart rhythm

Medications on next page

mailto:[email protected]


Patient’s name:

HSN:

DOB: dd/mm/yyyy

Posted Initial

ORDERS AND SIGNATURE of 2

Date & Time Practitioner Signature:

Practitioner Name (printed):


If CIWA Score is between 10 - 20:

Suggested regimens below. Choose EITHER fixed-dose diazepam OR LORazepam protocol NOTE: LORazepam is preferred for patients with significant liver or respiratory disease and those greater than 65 years of age:

Diazepam 5 mg tablets LORazepam 1 mg tablets Day 1: 10 mg ORALLY QID

Day 2: 10 mg ORALLY TID

Day 3: 10 mg ORALLY BID

Day 4: 10 mg ORALLY DAILY

Day 5: 5 mg ORALLY DAILY

Day 1: 2 mg ORALLY QID

Day 2: 2 mg ORALLY TID

Day 3: 1 mg ORALLY QID

Day 4: 0.5 mg ORALLY QID

Day 5: 0.5 mg ORALLY TID

If CIWA-Ar Score is less than 10: Give no medications and ideally repeat CIWA-Ar Score q4-6h as able

Discontinue monitoring when CIWA-Ar Score is 10 or less for 24 hours

Notify on-call physician immediately if:

Hallucinations associated with alcohol withdrawal develop

Hypertension (blood pressure greater than 140/90 mmHg), severe tremor, tachycardia (HR greater than 120 bpm) or irregular heart rhythm are noted

Medications: Diazepam 5 mg tablets as per above suggested protocol

Dispense daily for days

Other: _________________________________________________________________

Dispense a _____ day supply which equates to a TOTAL quantity of:

capsules (numeric): ___________________

capsules (written): ____________________

LORazepam 1 mg tablets as per above suggested protocol

Dispense daily for days

Other: _________________________________________________________________

Dispense a _____ day supply which equates to a TOTAL quantity of:

capsules (numeric): ___________________

capsules (written): ____________________

Thiamine 300 mg ORALLY x _____ days

Folic Acid 5 mg ORALLY x _____ days

Vitamin C 500 mg ORALLY x _____ days

Deliver above medications to patient in same frequency as specified in SHA OS-025



Page +1 of 2


A. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) Scale



Page +2 of 2


B. Prediction of Alcohol Withdrawal Severity Scale (PAWSS) Maldonado et al., 2014

Part A: Threshold Criteria: (1 point either) 1. Have you consumed any amount of alcohol (i.e., been drinking)

within the last 30 days? OR did the patient have a “+” BAL upon admission? IF the answer to either is YES, proceed with test:

Part B: Based on patient interview: (1 point each)

2. Have you ever experienced previous episodes of alcohol withdrawal?

3. Have you ever experienced alcohol withdrawal seizures?

4. Have you ever experienced delirium tremens or DT’s?

5. Have you ever undergone alcohol rehabilitation treatment?

(i.e. in-patient or out-patient treatment programs or AA attendance)

6. Have you ever experienced blackouts?

7. Have you combined alcohol with other “downers” like bendoziazepines or

barbiturates during the last 90’s?

8. Have you combined alcohol with any other substance of abuse during the last 90 days?

Part C: Based on clinical evidence: (1 point each)

9. Was the patient’s blood alcohol level (BAL) greater than 200 mg/dL? (SI units 43.5 mmol/L) OR For men: Have you consumed more than 3 standard drinks in the past 12 hours?

For women: Have you consumed more than 2 standard drinks in the past 12 hours?

10. Is there any evidence of increased autonomic activity?

(e.g. heart rate greater than 120 bpm, tremor, agitation, sweating, nausea)

Total Score:

Interpretation: Maximum score = 10. This instrument is intended as a SCREENING TOOL. The greater the number of positive findings, the higher the risk for the development of alcohol withdrawal syndrome (AWS).

A score of 4 or greater suggests HIGH RISK for moderate to severe (complicated) AWS; prophylaxis and/or inpatient treatment are indicated.

*Modification: In the event that BAL is not available, the Canadian Low Risk Drinking Guidelines threshold levels can be used.


sha-os-025a assisted self isolation tobacco and alcohol ......have you ever experienced previous...

Documents