Improving Alcohol Withdrawal Outcomes in Acute Care

Nurse Practitioner in the Stepdown Unit at Christiana Care Health System in Wilmington, DE. E-mail: gro.eracanaitsirhc@noslemj.

Medicine Outcomes Coordinator in the Performance Improvement Department at Christiana Care Health System in Newark, DE. E-mail: gro.eracanaitsirhc@enakim.

Research Facilitator for the Christiana Care Health System in Newark, DE. E-mail: gro.eracanaitsirhc@yenoomr.

Chief of the Division of Addiction Medicine for the Christiana Care Health System in Newark, DE. E-mail: gro.eracanaitsirhc@notroht.

Abstract

Context

Excessive alcohol consumption is the nation’s third leading cause of preventable deaths. If untreated, 6% of alcohol-dependent patients experience alcohol withdrawal, with up to 10% of those experiencing delirium tremens (DT), when they stop drinking. Without routine screening, patients often experience DT without warning.

Objective:

Reduce the incidence of alcohol withdrawal advancing to DT, restraint use, and transfers to the intensive care unit (ICU) in patients with DT.

Design:

In October 2009, the alcohol withdrawal team instituted a care management guideline used by all disciplines, which included tools for screening, assessment, and symptom management. Data were obtained from existing datasets for three quarters before and four quarters after implementation. Follow-up data were analyzed and showed a great deal of variability in transfers to the ICU and restraint use. Percentage of patients who developed DT showed a downward trend.

Main Outcome Measures:

Incidence of alcohol withdrawal advancing to DT and, in patients with DT, restraint use and transfers to the ICU.

Results:

Initial data revealed a decrease in percentage of patients with alcohol withdrawal who experienced DT (16.4%–12.9%). In patients with DT, restraint use decreased (60.4%–44.4%) and transfers to the ICU decreased (21.6%–15%). Follow-up data indicated a continued downward trend in patients with DT. Changes were not statistically significant. Restraint use and ICU transfers maintained postimplementation levels initially but returned to preimplementation levels by third quarter 2012.

Conclusion:

Early identification of patients for potential alcohol withdrawal followed by a standardized treatment protocol using symptom-triggered dosing improved alcohol withdrawal management and outcomes.

Introduction

Early identification and treatment of alcohol withdrawal syndrome using symptom-triggered dosing can reduce use of restraints, transfers to the intensive care unit (ICU), and progression to delirium tremens (DT).

Mokdad et al 1 used data from the Centers for Disease Control and Prevention in Atlanta, GA, for the Year 2000 and determined that excessive alcohol consumption was the third leading cause of preventable deaths in the US, with tobacco use being first and poor diet and physical inactivity second. Saitz et al 2 found that 17% of patients reported risky drinking behavior, and 77% of those patients, or 13% overall, were found to be alcohol dependent. Risky drinking was defined as more than 14 standard drinks per week or 4 or more drinks per occasion for men, for women as more than 11 drinks per week and as more than 3 drinks per week for people older than age 66 years.

Current evidence dictates the need for screening and early management of alcohol withdrawal syndrome to prevent progression of symptoms and/or onset of DT. 3 , 4 Early intervention and symptom-triggered dosing is recommended in managing alcohol withdrawal and preventing DT. 5 , 6 The management of patients with alcohol withdrawal syndrome is a challenging and resource-intensive process. 6

Patients experiencing alcohol withdrawal syndrome often place themselves and staff at risk of injury. Lansford et al 3 reported violence, including kicking, biting, scratching, and other violent episodes, in 36% of patients before they received a standardized care protocol. This rate was reduced to 8% in the protocol group. Phillips et al 7 developed a protocol to manage patients with alcohol withdrawal syndrome in the ICU. One of the reasons for developing the protocol was injury to staff that occurred because of violent patient behavior as patients withdrew from alcohol.

Alcohol use disorder includes alcohol dependence, commonly called alcoholism, and alcohol abuse. Alcohol dependence has the following characteristics: craving, loss of control, physical dependence, and alcohol tolerance. Patients with alcohol abuse may not fulfill family, work, or school responsibilities but are not physically dependent on alcohol. The alcohol-dependent patient is of most concern to us, because 6% of dependent patients go into withdrawal if untreated, and 10% of these are at risk of DT. 7 – 9

Alcohol withdrawal can manifest as nausea and vomiting; disorientation and clouding of the sensorium; tremors; diaphoresis; anxiety; tactile, auditory, and visual disturbances; and headache. If left untreated, alcohol withdrawal can lead to delirium, seizures, and possibly death.

This project was initiated at Christiana Care Health System, the largest provider of acute care in Delaware. As found in a pilot study, 7% of patients admitted to Christiana Care acknowledged drinking daily. Before 2009, Christiana Care had no standardized screening criteria for assessing risk of alcohol withdrawal syndrome, no consistent approach to treatment, and no formal method for monitoring and adjusting treatment outside the critical care units. Likewise, colleagues from other hospitals told us that they also experience problems managing patients with alcohol withdrawal and do not have robust screening and treatment protocols. At Christiana Care, identification of patients at risk of alcohol withdrawal syndrome, especially outside critical care units, was not timely and often occurred at the onset of severe symptoms. Delayed diagnosis and treatment of alcohol withdrawal syndrome resulted in several adverse patient and staff outcomes.

Because of adverse patient outcomes, the existing team for alcohol withdrawal management was enhanced to include nurses, physicians, a social worker, a pharmacist, a nurse from Performance Improvement, and a data analyst. The Patient Safety Committee charged the team with developing a system of assessment and management that would result in the following: 1) early identification and monitoring of patients at risk of alcohol withdrawal syndrome and 2) reduced variation in care through the adoption of evidence-based standards/guidelines and clinician order set. Regular intervals for reporting back were established.

The alcohol withdrawal team determined that identifying patients at risk of alcohol withdrawal syndrome was essential and that all adult inpatients should be screened for risk of this syndrome in a manner similar to other routine risk assessments. Finding a screening tool with known reliability and validity for detecting alcohol use disorders and pairing it with a symptom-based assessment tool were identified as priorities for broad implementation. The team used performance improvement techniques to determine the impact of instituting a bundled approach. This approach included screening of all adult inpatients for risk of alcohol withdrawal syndrome and using symptom-triggered management based on the revised Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) scores for those patients experiencing alcohol withdrawal syndrome or DT.

This report describes the development, implementation, and evaluation of a bundled approach to the management of alcohol withdrawal syndrome in the acute care hospital. The Alcohol Withdrawal Symptom Management Care Management Guideline was developed to be used by multiple clinical disciplines. This care management guideline includes an alcohol withdrawal risk assessment, the symptom-based CIWA-Ar assessment, two clinical algorithms, and a clinician order set. The Sedation Agitation Scale 10 was included to provide for ongoing assessment for oversedation ( Table 1 ).

Table 1.

Components of the Alcohol Withdrawal Symptom Management Care Management Guideline