Outcomes after Implementation of an Alcohol Withdrawal Protocol at a Single Institution

Eberly, Mary E.; Lockwood, Anna; Lockwood, Sean; Davis, Kelly W.

doi:10.1310/hpj5109-752

Cited by 11 publications

(7 citation statements)

References 15 publications

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“…We performed a calculation of statistical power a priori based on a minimally clinically significant finding of 24 hours difference in median duration of benzodiazepine use between both groups. A recent study has shown that institution of an AWS treatment protocol in medical inpatients led to a significant difference in treatment duration of approximately 30 hours 7 . We believe that given the high variability of the population being studied, the standard deviation would be approximately 48 hours.…”

Section: Methodsmentioning

confidence: 88%

“…While numerous studies have demonstrated the effectiveness of such AWS protocols in decreasing morbidity associated with AWS on medical and surgical wards, 2‐6 many of these exclude patients with psychiatric comorbidities, and there are no published studies, to our knowledge, investigating the efficacy of AWS evaluation and treatment methods exclusively for psychiatric inpatients. One study evaluating the effects of implementation of a symptom‐triggered protocol included psychiatric inpatients in addition to medical patients 7 . Another study evaluating the impact of gabapentin in conjunction with benzodiazepines for management of AWS was conducted using psychiatric inpatients undergoing symptom‐triggered therapy, but did not evaluate the safety nor effectiveness of the symptom‐triggered protocol 8 …”

Section: Introductionmentioning

confidence: 99%

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Evaluation of a Novel Protocol for Assessment and Treatment of Alcohol Withdrawal Syndrome in Psychiatric Inpatients

et al. 2020

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Background and Objectives Despite the high incidence of alcohol withdrawal syndrome (AWS) in psychiatric inpatients, standardized methods for assessing and treating AWS have been studied only once before in this population. We evaluated a novel AWS assessment and treatment protocol designed for psychiatric inpatients. Methods This retrospective cohort study evaluated outcomes before and after implementation of the protocol. We collected consecutive data on patients (N = 138) admitted to inpatient psychiatric units at a single center. Participants were patients admitted for nonsubstance‐related psychiatric reasons, who were also at risk for developing AWS. Those who developed AWS were treated with either (a) treatment as usual (TAU) or (b) a novel standardized protocol. The primary outcome was duration of benzodiazepine treatment for symptoms of alcohol withdrawal. Secondary outcomes included cumulative benzodiazepine dose administered, treatment duration, and incidence of complications. Results Of 138 participants, 83 received TAU and 55 were assessed and treated with the novel protocol. Median duration of benzodiazepine treatment following protocol implementation was 19.7 hours (interquartile range [IQR], 0‐46) prior to implementation (TAU) and 0 hours (IQR, 0‐15) following protocol implementation (protocol group) (P < .0001). Median benzodiazepine dose (in diazepam equivalents) administered to participants was 30 mg (IQR, 0‐65) for TAU and 5 mg (IQR, 0‐30) for the protocol group (P < .001). Adverse events before and after implementation occurred in 4.8% and 0%, respectively (P = .15). Conclusion and Scientific Significance This study provides preliminary evidence for the efficacy and safety of a novel standardized AWS protocol for psychiatric inpatients. This is the first known study assessing an AWS assessment and treatment protocol designed for psychiatric inpatients. (Am J Addict 2020;29:500–507)

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Section: Methodsmentioning

confidence: 88%

Section: Introductionmentioning

confidence: 99%

Evaluation of a Novel Protocol for Assessment and Treatment of Alcohol Withdrawal Syndrome in Psychiatric Inpatients

et al. 2020

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“…Prior studies in AWS management have established the superior effectiveness of symptom-triggered AWS protocols over fixed-dose tapering (or provider preference) in reducing AWS-related complications including DT, need for intubation, and escalation in care to an IMU or ICU. [14][15][16] Other studies have also demonstrated the effectiveness of symptom-driven approaches to decrease the length of hospitalization, 15,17,18 lower the required benzodiazepine exposure necessary to treat AWS, 7,12,15,[17][18][19][20][21][22][23][24][25][26][27][28] and reduce the duration of treatment with benzodiazepine sedation. 7,12,[22][23][24][25][26][27]29 Although there are other effective validated indices described in the literature, 29 the CIWA-ar remains one of the most widely accepted.…”

Section: Discussionmentioning

confidence: 99%

“…Long-term persistent exposure to alcohol results in altered central nervous system function such that abrupt cessation of alcohol use leads to a spectrum of symptoms ranging from mild tremor to seizures or delirium tremens (DT), a diagnosis associated with a 15%-20% mortality rate without appropriate medical care. 7 Furthermore, although the course of withdrawal can be mild, it has been estimated that 20% of patients in AWS will experience more serious manifestations meriting hospitalization for observation and treatment. 8 In addition, patients hospitalized for other medical or surgical reasons, and who experience symptoms of AWS, can have higher morbidity and mortality, and increased length of hospitalization.…”

Section: Introductionmentioning

confidence: 99%

Assessment of a modified MINDS‐based protocol for management of alcohol withdrawal syndrome on an inpatient medical service

Krcmarik,

Hulley,

Huang

et al. 2023

Pharmacotherapy

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ObjectiveTo determine if a novel symptom‐based alcohol withdrawal syndrome (AWS) protocol in a US Veterans cohort leads to significant clinical improvements in patient outcomes and safety.BackgroundPrior studies of AWS management, oftentimes using the revised version of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA‐Ar) index, have demonstrated the effectiveness of symptom‐triggered therapy for AWS. The Minnesota Detoxification Scale (MINDS) is an alternative to the CIWA‐Ar index but remains unevaluated outside of the intensive care unit (ICU) setting. This study assesses outcomes in AWS management prior to and after the implementation of a novel MINDS‐based AWS protocol (SDAWP) utilizing a revised MINDS index (MINDS‐rev) in an inpatient medical ward setting.MethodsRetrospective cohort study including encounters prior to (n = 342) and after (n = 338) the implementation of the protocol. Pre‐ and post‐protocol encounters were selected by combinations of diagnostic codes and charting elements. Outcome measures of AWS management were obtained in both groups. The primary endpoint was median total benzodiazepine exposure. Secondary outcomes included median length of hospitalization, median duration of benzodiazepine administration, and the incidence of complications.ResultsThe median total benzodiazepine exposure in the post‐SDAWP group was significantly lower than the pre‐SDAWP group (21.2 vs. 12.0 mg, p < 0.0001) and for a significantly shorter median duration of time (4.0 vs. 3.0 days, p < 0.0001). There was no significant difference in the median length of stay (4.0 vs. 4.0 days, p = 0.50). The incidence of delirium tremens (21 vs. 7, p = 0.01) and need for transfer to a higher level of care (33 vs. 12, p = 0.002) was significantly lower in the post‐SDAWP group.ConclusionThe SDAWP has provided significant improvements in AWS management in our institution and may potentially serve as a template for wider use in other inpatient settings.

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“…One study found no reductions in LOS, total BZD use, or safety events 14 . Another study found reductions in the average cumulative BZD use but no improvement to LOS or safety 15 …”

mentioning

confidence: 99%

Assessment of a Hospital-Wide CIWA-Ar Protocol for Management of Alcohol Withdrawal Syndrome

Melkonian

Patel

Magh

et al. 2019

Mayo Clinic Proceedings: Innovations, Quality & Outcomes

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Objective To determine if a hospital-wide symptom-based alcohol withdrawal protocol may result in significant clinical improvements to patient outcomes, safety, and hospital efficiency. Methods Retrospective/prospective cohort study between January 1, 2016 and December 31, 2016 (pre-protocol), and between March 1, 2017 and August 7, July 2017 (post-protocol). Pre-protocol patients were identified retrospectively using International Classification of Diseases, 10 th revision codes (F10.1, F10.2, and Z71.4). Post-protocol patients were identified by the use of a unique alcohol withdrawal order set in their electronic medical record. The primary endpoint was average length of stay. Secondary outcomes included death, escalation of care as defined as requiring intensive care unit (ICU) consultation or the rapid response team, average ICU length of stay, respiratory failure, average benzodiazepine usage, and incidence of seizures. Results The study included 276 patients in the pre-protocol group and 145 patients in the post-protocol group. There was a significant reduction found in the primary endpoint of average length of stay (7.15 ± 6.5 days vs 5.7 ± 5.6 days; P =.02). There was a significant reduction in the average benzodiazepine use, use of adjunctive medications, need for ICU consultation or rapid response team, respiratory failure, average ICU length of stay, use of neurologic imaging, and the need for lumbar puncture. Conclusion Implementation of a Clinical Institute Withdrawal Assessment for Alcohol, Revised–based alcohol withdrawal protocol may significantly improve quality of care, patient safety, and treatment effectiveness in a large, mixed medical/surgical, urban community-based academic medical center.

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Outcomes after Implementation of an Alcohol Withdrawal Protocol at a Single Institution

Cited by 11 publications

References 15 publications

Evaluation of a Novel Protocol for Assessment and Treatment of Alcohol Withdrawal Syndrome in Psychiatric Inpatients

Evaluation of a Novel Protocol for Assessment and Treatment of Alcohol Withdrawal Syndrome in Psychiatric Inpatients

Assessment of a modified MINDS‐based protocol for management of alcohol withdrawal syndrome on an inpatient medical service

Assessment of a Hospital-Wide CIWA-Ar Protocol for Management of Alcohol Withdrawal Syndrome

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