Psychosomatics 49:292-299, July-August 2008
doi: 10.1176/appi.psy.49.4.292
© 2008 Academy of Psychosomatic Medicine
Successful Implementation of an Alcohol-Withdrawal Pathway in a General Hospital
Jennifer Repper-DeLisi, APRN, BC,
Theodore A. Stern, M.D.,
Monique Mitchell, APRN, BC,
Mary Lussier-Cushing, APRN, BC,
Barbara Lakatos, APRN, BC,
Gregory L. Fricchione, M.D.,
Joan Quinlan, M.P.A.,
Martha Kane, Ph.D.,
Rhodes Berube, M.P.H.,
Mark Blais, Psy.D.,
Virginia Capasso, Ph.D., APRN, BC,
Firdosh Pathan, R.Ph., M.S.,
Andrew Karson, M.D., M.P.H., and
Michael Bierer, M.D., M.P.H.
Received September 30, 2006; revised January 3, 2007; accepted January 11, 2007. From Massachusetts General Hospital, Boston, MA. Send correspondence and reprint requests to Jennifer Repper-DeLisi, APRN, BC, Dept. of Nursing, Massachusetts General Hospital, Blake 11, Boston, MA 02114. e-mail: jrepperdelisi{at}partners.org
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: Although alcohol use and abuse are common among general-hospital inpatients, many patients are inadequately assessed and treated for alcohol withdrawal. OBJECTIVE: The purpose of this study was to determine whether the implementation of a clinical pathway for the treatment of alcohol withdrawal in medical inpatients would result in improvements in clinical practice and patient outcomes. METHOD: Authors retrospectively reviewed 80 patient records (including 40 of those treated before the implementation of a pathway and 40 of those treated after pathway implementation). RESULTS: Assessment procedures and ordering patterns of physicians (medical house staff and staff physicians) shifted in a fashion consistent with the new treatment guidelines. Patient outcomes (e.g., length of stay and the incidence of delirium) improved for those patients who received benzodiazepines within the range of the pathway guidelines. CONCLUSIONS: Timely assessment and staff education can shift prescription patterns, increase patient monitoring, and reduce costs associated with alcohol withdrawal.
Key Words: Alcoholism • Withdrawal Treatment
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INTRODUCTION
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Alcohol use and abuse are exceedingly common in the general population, and one in four patients admitted to medical and surgical services in general hospitals has an alcohol use disorder.1 Among the most hazardous of alcohol-related conditions (e.g., Wernicke’s encephalopathy, Korsakoff’s psychosis, alcohol-induced hepatitis, and cirrhosis) is alcohol withdrawal, which is a direct consequence of abstinence. Although manifestations of the alcohol withdrawal syndrome (AWS) may be minor, if pre-admission use of alcohol is heavy and the pattern goes unrecognized and untreated, AWS may be severe, characterized by delirium tremens (DTs) and/or seizures.
Not uncommonly, medical or surgical comorbidity often complicates both the diagnosis and the treatment of AWS.2,3 When symptoms of AWS are attributed to medical or surgical conditions, inadequate treatment means that the AWS can run rampant and exacerbate the comorbid condition (e.g., myocardial infarction). Conversely, signs and symptoms of an underlying medical illness (e.g., pneumonia or pancreatitis) may be attributed to AWS and go overlooked; this delays recognition and treatment of medical problems. Such difficulties in diagnosis and treatment contribute to longer, costlier, and more complicated hospital stays.3,4
Throughout the country, clinical pathways are being used to improve the management of a variety of clinical conditions. By creating a blueprint for care, diagnosis and treatment may be initiated more rapidly; practice variation can be minimized; and interdisciplinary communication can be improved.5,6 Clinical outcomes (e.g., patient satisfaction and staff efficiency) associated with the implementation of pathways vary, but the application of numerous guidelines has met with success.6,7
Many protocols for the treatment of alcohol withdrawal have been established; most studies of their use indicate that implementation of a protocol improves patient outcomes.8,9 However, few controlled studies of treatments exist,2 and even fewer have been developed and tested in acutely (medically or surgically) ill patients.10,11 Most treatment regimens for the prevention and treatment of AWS have been developed and tested in detoxification centers, where patients do not manifest serious medical problems.10 Given that alcohol-dependent patients account for a large proportion of acute medical/surgical inpatient admissions in general hospitals, that they experience longer hospital stays, have more frequent readmissions, and are encountered by clinicians in every discipline, it is crucial that attention be paid to this problem.1,12,13
We sought to determine whether the creation, implementation, and outcome of a pathway for the diagnosis and treatment of medical and surgical inpatients at risk for and with AWS would result in improved practice patterns and economic outcomes. Specifically, we hypothesized that medical and nursing staff would change their treatment practices (i.e., that they would order standing [not PRN] medications based on a patient’s alcohol use and symptom severity, that their patients would be examined more frequently, that they would increase their use of specialty consultation, and that they would communicate more regularly with each other at the bedside). Anticipated results included fewer complications (e.g., delirium), lower hospital costs, and shorter lengths of stay (LOS) for patients at risk for alcohol withdrawal syndrome.
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METHOD
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Subject Selection
After approval of the hospital’s Institutional Review Board (IRB), patients were identified retrospectively through a screening of discharge diagnoses for alcohol withdrawal and selected from one of our medical floors after a secondary review of hospital admission and discharge notes to confirm the diagnosis. Patients were included if the record indicated alcohol consumption within 2 weeks of admission and/or withdrawal or treatment for AWS during the index admission. A group of 80 patients comprised the sample; 40 patients in the pre-pathway group ("Pre") were identified between October 2002 and May 2003, and 40 patients in the post-pathway group ("Post") were identified between October 2003 and June 2004. These periods are roughly matched for phase of the academic year, controlling for any annual training effect of house staff. Patients in the Pre- group were treated with benzodiazepines at the discretion of the medical staff (i.e., without benefit of a protocol). Patients in the Post- group were treated after initiation of an educational program with medical and nursing staff about alcohol withdrawal and its treatment and about the guidelines of the new pathway. Bedside consultation from Psychiatry and the Psychiatric Nursing Consultation Services was available upon request of staff during both the pre- and post-pathway periods.
Data Collection
Medical records for all 80 patients were reviewed retrospectively. Demographic information, clinical characteristics (e.g., age, gender, insurance provider, admission source, admission diagnosis, factors associated with alcohol use, and alcohol history), and pathway compliance measures for the first 3 days of admission (e.g., number of vital signs taken; benzodiazepine timing, dose, and order patterns; and use of Psychiatry and Psychiatric Nursing Consultation Services) were obtained.
Data Analysis
Analyses were performed with SPSS for Windows (Version 14.0). Variables were compared by t-test; two-tailed p values were obtained, and 0.05 was set as the level of significance. Medians were reported for variables without normal distributions (non-parametric statistics were used to analyze all non-normal data). Dichotomous variables were analyzed with chi-square tests.
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RESULTS
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The demographic and clinical characteristics of the 80 patients studied are shown in Table 1. The Pre and Post groups were not significantly different with respect to age, gender, or their insurance provider. More patients were men, with a mean age of 50.4 years (pre-pathway) and 47.1 years (post-pathway). Virtually all patients were admitted from the hospital’s Emergency Department (ED), and the majority had public insurance or were uninsured. A large percentage of patients (68% pre-pathway and 88% post-pathway) presented with a history of alcohol-related problems, including alcohol-withdrawal seizures (30% pre-pathway, 35% post-pathway), and DTs (15% pre-pathway, 7.5% post-pathway). There were significantly more previous admissions for detoxification in the post-pathway group: 42.5% in pre-pathway and 77.5% in post-pathway, ( 2[1]=10.20; p<0.01). Comorbid conditions that may worsen during the course of withdrawal were similar in both groups (37% pre-pathway and 35% post-pathway); most common was a history of hypertension or myocardial infarction.
A large percentage of patients (42.5% pre-pathway and 30% post-pathway) presented to the hospital in active alcohol withdrawal. Of those, 12.5 % in the pre-pathway and 10% in the post-pathway experienced withdrawal seizures either just before or upon admission to the hospital. Although a broad range of active medical problems were noted on admission, several conditions (e.g., cardiac, hepatic, gastrointestinal, trauma, and metabolic derangements) were evident in at least 15% of the patients. Most patients (85% pre-pathway and 57% post-pathway) had several admitting diagnoses.
Compliance measures are presented in Table 2. With the introduction of the pathway, patients were more likely to be assessed for the amount and frequency of their alcohol consumption, but the CAGE questionnaire to screen for alcohol dependence remained infrequently used. As Table 2 shows, the consultation practices of the medical staff changed after the implementation of the pathway. Staff continued to seek Psychiatry consultations at a consistent rate (50% pre-pathway and 57.5% post-pathway), however the percentage of patients receiving Psychiatric Nursing consultations (consultations performed by advanced-practice clinicians for a wide range of clinical problems and problematic behaviors) increased significantly from 55% pre-pathway to 77.5% post-pathway (2[1]=4.53; p<0.05) Vital signs were assessed more frequently for patients during the first 3 days of admission in the post-pathway group. The pre-pathway group had on average of 20.03 (standard deviation [SD]: 12.52) vital-sign checks over the first 3 days of hospitalization, as compared with 25.89 (SD: 17.13) for the post-pathway group. When the impact of delirium on vital-sign checking is controlled for, this difference is significant (ANCOVA; F[2,56]=4.95; p<0.05). To allow for statistical comparison of benzodiazepine use, diazepam dosing was converted into lorazepam-equivalents, using a 5:1 conversion rate. Figure 1 shows the median daily standing dose of benzodiazepines pre- and post-pathway implementation over the first 3 days of admission. Mann-Whitney tests showed no significant daily median dose differences between the two groups. However, Figure 2 shows the percent of benzodiazepine administered as a standing or fixed-dose (versus as-needed or "prn"). Independent t-tests showed that patients in the post-pathway group received a significantly higher percentage of their benzodiazepine medication as a standing dose over the first 3 days of hospitalization (Day 1: t[76] = –2.49; p<0.05; Day 2: t[68] = –2.89; p<0.01; Day 3: t[53] = –2.36; p<0.05).
Evidence of delirium was determined from documentation in the medical record by a nurse or a physician. Criteria were derived from the DSM–IV features of delirium including a change in cognition (e.g., disorientation and/or confusion) and/or perceptual changes (e.g., delusions and/or hallucinations). The incidence of delirium was lower in the post-pathway group (52% for the pre-pathway group and 40% for the post-pathway group), but the chi-square test revealed this difference to be non-significant. However, when the severity of past alcohol abuse and the total dose of benzodiazepine received in the emergency room were covaried (ANCOVA) the post-pathway group had significantly fewer cases of delirium than did the pre-pathway group (F[3,76]=4.01; p<0.05).
A substantial number of patients (20% overall) were treated with benzodiazepine doses that exceeded the recommendations of the pathway. These patients were excluded from a secondary analysis in order to clarify the outcome for patients who received the recommended doses. Figure 3 shows the distribution of lorazepam-equivalents for the first 3 days of admission between groups for those patients who received no more than 48 mg/day (pre-pathway: 33; post-pathway: 31). Dosing was higher on Day 1 in the post-pathway group (median: 7.7 mg pre-pathway vs. 11.0 mg post-pathway) and lower by Day 3 (median: 6.5 mg pre-pathway vs. 4.0 mg post-pathway). Mean LOS dropped from 5.4 days (SD: 4.89) pre-pathway to 4.0 days (SD: 2.73) post-pathway, and incidence of delirium dropped from 42% pre-pathway to 31% post-pathway; however, these differences were not statistically significant (see Table 3). Patients who received more than 48 mg on any 1 of the first 3 days of admission (N=16; pre-pathway: 7, post-pathway: 9) had a longer LOS (mean: 14.25 days) than patients who received less (mean: 4.73; t[78]=6.24; p<0.001). Changes in mental status were seen in 88% of patients; all were restrained, and 38% had presented to the hospital with a seizure.
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DISCUSSION
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Alcohol withdrawal is a prevalent problem among medical and surgical inpatients; it results in longer, costlier, and more complicated hospital stays. Consistent with the literature, we found that delayed or insufficient treatment was associated with poorer outcomes.3,4 Previous protocols at our institution, using a symptom-triggered approach, were underutilized and impractical on busy medical/surgical floors. Early symptoms of AWS had been overlooked; systematic assessments of patients were infrequent; and patients often fell behind in their course of treatment. High turnover in nursing staff and a monthly rotation of physicians also contributed to inconsistencies in the delivery of care and delays in management.
Implementation of practice change can be challenging, as individual practices and time-honored traditions often prevail. Although changing a specific behavior (such as ordering a diagnostic test) can be a relatively simple management task, altering the diagnosis, the treatment, and the monitoring of a particular syndrome (such as alcohol withdrawal) presents formidable challenges.14 Further complicating the problem of practice change in the treatment of AWS is the limited knowledgebase of most inexperienced physicians and nurses. Despite its prevalence and the severity of the problem, alcohol withdrawal receives little attention in training programs. Well-respected texts for nursing and medicine reflect this lack of emphasis and fail to provide effective protocols for new practitioners.15–17 The introduction of recommended changes in practice patterns should include broad-based real-time education (with readily available specialty consultation) and detailed steps for the negotiation of the complex care that medically or surgically ill patients experience in the context of alcohol withdrawal.
Pathway Development and Implementation
We created a multidisciplinary task force comprising physicians, psychiatric clinical nurse-specialists, pharmacists, addiction experts, and administrators to create a better solution to a recurrent problem (i.e., the inability to recognize and to treat AWS in medical/surgical inpatients; Quinlan JA, Stern TA: Improving the recognition and treatment of alcohol related problems in the general hospital. Unpublished manuscript, 2006). From an extensive literature review and evaluation of external and internal practices (Blais M; personal communication, 2006), we learned that no "gold standard" existed for the treatment of inpatients with AWS. Although there has been general agreement that benzodiazepines are the treatment of choice for AWS, the determination of when to treat and how much medication to give varies considerably.2 Treatment usually involves titration of a benzodiazepine to control the symptoms of withdrawal; this is then followed by a gradual taper for detoxification. Medications are typically provided either in fixed ("standing") amounts (i.e., the patient receives a predetermined dose either prophylactically, when at risk for AWS, or when symptoms appear) or in a symptom-triggered fashion (i.e., the patient is monitored at intervals and receives doses based on the severity of the presentation). Clinical trials that compare one benzodiazepine to another, though decades old, demonstrate that all benzodiazepines are effective for the treatment of AWS.2
Timely treatment relies on the accurate identification of patients at risk for AWS. Effective screening tools, including the CAGE questionnaire, the Michigan Alcohol Screening Test (MAST), and the AUDIT, can guide bedside clinicians to timely treatment for alcohol-related problems.18,19 Unfortunately, few care-providers in general hospitals routinely use these screening tools.20,21
To assess symptoms of AWS, the Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA) is most commonly used as both a diagnostic and symptom-monitoring tool.22 Although there are compelling data to support its use for uncomplicated alcohol withdrawal,8,9 many of the symptoms assessed with this tool are non-specific and may be misinterpreted (i.e., if they are identified as symptoms that result from another medical condition). As a result, symptom-triggered therapy becomes problematic. The American Society of Addiction Medicine (ASAM) acknowledges this problem and cautions use of the CIWA and other assessment scales for patients with comorbid illness.2
The Massachusetts General Hospital Protocol for Prevention and Treatment of Alcohol-Withdrawal Syndrome
Our pathway was developed to increase the recognition of those at risk for withdrawal problems, to treat patients before they became symptomatic (i.e., to prevent withdrawal symptoms), and to facilitate aggressive treatment for patients in alcohol withdrawal. The approach required the sequential assessment of six domains: patient report of amount and frequency of alcohol consumption and/or blood alcohol level; the CAGE score; vital signs; presence/absence of withdrawal symptoms; presence/absence of delirium; and patient risk factors (e.g., advanced patient age, history of alcohol-related events, and comorbid conditions that could result in more severe withdrawal symptoms or a worsened medical condition) that lead a clinician to one of six possible treatment options. This stepwise method helped to ensure a reliable approach. The multi-treatment algorithm (Figure 4) allowed providers to individualize care and permitted greater variability of patient presentation for pathway inclusion.
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FIGURE 4. Alcohol-Withdrawal Pathway
This clinical pathway and taper suggestions are intended as a diagnostic tool and must not be used to replace clinical judgment or diagnostic reasoning. © MGH Alcohol Pathway Working Group.
SBP: systolic blood pressure; DBP: diastolic blood pressure; P: pulse; T: temperature; Sx: symptoms; Hx: history; AWS: alcohol withdrawal syndrome; VS: vital signs; DTs: delirium tremens; MVI: multivitamin; RR: respiration rate; HO: house officer.
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Each treatment option provided a choice of either diazepam or lorazepam at varying doses. These two benzodiazepines were chosen to provide a longer-acting and a shorter-acting drug with different metabolic pathways; one agent (lorazepam) is metabolized by conjugation, making it preferable for those with impaired hepatic function; the other (diazepam) is metabolized by both oxidative metabolism and conjugation. In this way, treatment could be tailored to a patient’s clinical condition. Each drug could be administered by multiple routes (orally or intravenously), a necessary option for medically or surgically ill patients.
Multiple treatment options were allowed for individualized care. Our system was designed to prevent the signs and symptoms of alcohol withdrawal; it included three prophylactic options (based on the quantity of alcohol consumed and the patient’s risk factors). Active withdrawal was treated with one of three options, on the basis of vital-sign changes and symptom severity (i.e., with or without delirium); it included an option for the rapid provision of large doses of benzodiazepines to control severe symptoms of alcohol withdrawal.
Given the demands of a fast-paced, high-acuity environment, with competing priorities, a heavy patient-care load, and relatively inexperienced (although supervised) front-line physician trainees and nurses, a standing-order regimen for benzodiazepine dosing was chosen. This ensured that systematic assessment and administration of medications was done at regular intervals. Rigorous "hold" parameters (based on vital signs and the level of consciousness) helped to ensure safe administration and the routine evaluation of a patient’s response to treatment. We realized that some patients could be placed at risk for extra doses of a benzodiazepine before a dose was held, but viewed the risk of undertreatment and rapid development of AWS to be of greater concern. Guidelines for the reevaluation of a patient’s treatment and advice on when to consider consultations from Psychiatry and Pharmacy staff were also included.
To ensure collaboration at the bedside, implementation included a multidisciplinary and multifaceted training program to educate staff and to increase awareness of the new approach to treatment. Several settings were used to reach caregivers at many levels within the institution: unit- and team-based training modules; nursing and medical grand rounds; system-wide informational posters; an alcohol-withdrawal pathway intranet site; and bedside consultation on a case-by-case basis (upon staff request).
Results of the pilot study presented in this report are encouraging. Shifts in practice were consistent with the new pathway’s parameters, and a modest improvement in outcomes (incidence of delirium and length of stay) was noted for patients who received benzodiazepines that were within our treatment recommendations.
Study Limitations
The relatively small sample size limited our analysis and conclusions. Resident rotations of 2 to 4 weeks limited our ability to maintain and update the education for medical practitioners. However, consistent nursing involvement was noted. Patients were selected on the basis of identification of AWS as a primary post-discharge diagnosis. This may have resulted in the selection of a more severely ill subgroup of patients and effectively eliminated patients for whom prophylaxis was used. Also, patients who presented with withdrawal seizures were included in the cohort. Such patients would be expected to have a higher rate of complications from AWS and to have a potentially higher level of medical acuity. This is supported by our data: six of the seven patients who presented with a seizure received benzodiazepines in doses that exceeded the recommendations of the pathway.
Because the study design was retrospective in nature, we were unable to follow clinician decision-making when applying the pathway; therefore, no inferences could be made about whether it was either applied correctly or incorrectly (to either over- or under-medicate a particular patient). Some variables (e.g., change in mental status and its causes) were difficult to assess or were absent from the medical record. For example, the diagnosis of altered mental status, although reduced in the post-pathway group, represented a large fraction of both groups. We did not have information to identify the cause for individual patients: Was the change due solely to alcohol withdrawal (DTs), a part of a more complicated delirium associated with multiple factors, or a result of the treatment itself?
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CONCLUSION
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The prevalence of alcohol use and abuse is high among general-hospital patients, making AWS a problem that general-hospital staffs need to face. Implementation of a pathway for the identification of patients at risk for or with AWS (and who would benefit from treatment) is of clinical importance (i.e., it will reduce the risk of complications related to inadequate and untimely treatment of AWS, and it will reduce LOS, hospital costs, and medical comorbidity associated with the AWS). However, a prospective study with attention to the complicated presentation of patients would more accurately delineate the possible cause or causes.
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ABSTRACT
INTRODUCTION
