A‘symptom-triggered’approachtoalcoholwithdrawal management

JayMurdochandJanetMarsdenJayMurdochisLeadNurseforAlcoholLiaison,PennineAcuteHospitalsNHSTrust,Manchester;JanetMarsdenisProfessorofOphthalmologyandEmergencyCare,ManchesterMetropolitanUniversity

Acceptedforpublication:February2014

Inacutehospitalsettings,alcoholwithdrawaloftencausessignificantmanagementproblemsandcomplicatesawidevarietyofconcurrentconditions,placingahugeburdenontheNHS.Asignificantnumberofcriticalincidentsaroundpatientswhowereundergoingdetoxificationinageneralhospitalsettingledtotheneedforaprojecttoimplementandevaluateanevidence-basedapproachtothemanagementofalcoholdetoxification—aprojectthatincludedapre-interventioncasenoteaudit,theimplementationofanevidence-basedsymptom-triggereddetoxificationprotocol,andapost-interventioncasenoteaudit.Thischangeinpracticeresultedinanaveragereductionofalmost60%inlengthofhospitalstayanda66%reductionintheamountofchlordiazepoxideusedindetoxification,aswellashighlightingthat10%ofthesamplegroupdidnotdisplayanysignsofwithdrawalanddidnotrequireanymedication.Evenwiththesereductions,nopatientpost-interventiondevelopedanyseveresignsofwithdrawalphenomena,suchasseizuresordeliriumtremens.Thesavingstothetrust(ThePennineAcuteHospitalTrust)areobvious,butthedevelopmentofaconsistent,qualityservicewillleadtofewerlong-termnegativeeffectsforpatientsthatcanbecausedbydetoxification.Thisworkisaprojectevaluationofalocallyimplementedstrategy,which,itwashypothesised,wouldimprovecarebyprovidinganindividualisedtreatmentplanforthemanagementofalcoholwithdrawalsymptoms.Keywords:Detoxification■Alcohol■Chlordiazepoxide■Symptom-triggeredapproach

Alcoholabuseanddependencerepresentsaveryserioushealthproblemworldwidewithmajorsocial,interpersonalandlegalconsequences(Amatoetal, 2010). Despiteanincreasingawarenessofitsdangersamongboththemediaandthemedical profession,alcoholremainsaseriousandgrowingpublichealthconcernintheUK(Owensetal,2005).AccordingtoAlcoholConcern(2010),thenumberofdependentdrinkersinEnglandnowstandsat1.6million.Thenumberofalcohol-relatedadmissionsinEnglandisabout onemillionperyearandhasbeensteadilyrising(PerkinsandHennessey,2014),anincreaseof100%since2002/3(AlcoholConcern,2010).AlcoholConcernstatesthatthecosttotheNHSis£2.7billioneveryyearandisexpectedtocontinuetoriseto£3.7billion(AlcoholConcern,2010).Althoughalcoholuseandabusearecommonamonggeneralhospital inpatients, many patients are inadequately assessed and treated for alcohol withdrawal(Repper-Delisietal,2008).Alcoholwithdrawalsyndrome(AWS)isaclusterofsymptomsthatmaydevelopinalcohol-dependentpeopleafter thecessationof (or reduction in)heavyandprolongedalcoholuse(AmericanPsychiatricAssociation (APA), 2000;World Health Organization (WHO), 2010). AWS inevitably occurs as alcoholconsumption ceases on admission to hospital, whether specifically for detoxification (‘detox’) or as aconsequenceofadmissionforotherproblems.This project arose from the trust’s alcohol specialist nurse’s perception that the team tended to beapproachedtoconsultonalcoholdetoxificationonlywhenthingswent slightly

‘wrong’ suchaswhenapatient’ssymptomsexacerbatedand he/she became difficult and time-consuming to manage. They were worried about a lack of education in all clinicians aboutdetoxificationandalackofevidence-basedprotocolstoassistinpatientcare.Asignificantnumberofcriticalincidentsinvolvingpatientswhowereundergoingdetoxificationaddedtotheneedforaproject to implement and evaluate evidence-based approaches to the management of alcoholdetoxification.Thisproject was developedtostandardisealcoholdetoxificationregimesacrossasingle-sitehospitalduetoperceptionsthatexistingregimeswerenotevidence-basedandwerenotconsistent.

AWSThe clinical presentation of AWS varies frommild to serious. The onset of symptoms typicallyoccursupto48hoursafterthelastconsumptionofalcohol,andupto72hoursifdeliriumtremensare considered (Amato et al, 2010). Delirium tremens occurs in only about 5% of patientsundergoing alcohol withdrawal, but has the highest mortality rate: 5–20% in inappropriatelymanagedpatients. It isamedicalemergencyandisanadvancedstateofautonomichyperactivity.Thereissubstantialindividualvariationintheclinicalmanifestationsofalcoholwithdrawal,rangingfromverymildtremorandirritabilitytosignificantautonomichyperactivity(e.g.sweatingorpulserategreaterthan100beatsperminute(APA,2000;Wetterlingetal,2001;Amatoetal,2010).TheDiagnosticandStatisticalManualofMentalDisorders(DSM-IV) (APA, 2000) continues the symptom listwith the following symptoms: tremor, insomnia,nausea or vomiting, transient visual, tactile or auditory hallucinations or illusions, psychomotoragitation, anxiety and seizures. To define AWS, the patient must have two or more of thesesymptomsfollowingcessationorreductionofalcohol(McKeon,2008).The relation between alcohol intoxication, dependence, tolerance and withdrawal is not fully

understood.ButwedoknowthatthereisaclearrelationbetweenalcoholandchangesDevelopmentofthetool,educationand implementationWithdrawalseverityvariesgreatlyandtheamountofmedicationneededtocontrolsymptomscanalsovarysignificantly.Chlordiazepoxideistypicallyusedinpractice(NICE,2010b),andwasthereforethe drug of choice for the protocol, though diazepam and lorazepam can be equally efficacious(Asplundetal,2004).Chlordiazepoxideisusuallyadministeredinpredeterminedprophylacticdosingschedulesvaryingbetween3and10days (Daeppen et al, 2002;McGregor et al, 2003; Saitz, 2004;McKinley,2005;NICE,2010b).Althoughthismethodisusedfrequentlythroughouthospitals,predeterminedfixeddosingregimensmay subject many patients to unnecessary medication, over-sedation and longer hospital stays(Asplundetal,2004;Saitzetal,2004;HardernandPage,2005;NICE,2010a;NICE,2010b).Saitzetal(2004)state that many patients can safely undergo withdrawal from alcohol comfortably and withoutpharmacologicalintervention,whichwasseenintheresultsofthisproject.Itisclear,then,thatamoreindividualisedapproachtomanagementwouldbenefitpatients.Thiswasachieved using a symptom- triggered therapy protocol, consisting of monitoring patients andproviding medication only when symptoms of alcohol withdrawal developed. Symptoms wereidentifiedwithavalidatedassessment tool, the revisedClinical InstituteofWithdrawalAssessmentScale (CIWA-ar) (McKeon, 2008). The symptom- triggered approach has demonstrable success(Daeppenetal,2002;Dayetal,2004;HardernandPage,2005)andisrecommendedbyNICE(2010a).The CIWA-ar scores the severity of nausea, sweating, agitation,headache, anxiety, tremor, sensorydisturbances and orientation, and is easy to use (McKeon, 2008). Repeated scoring at suitable

intervals monitors the response to treatment and helps determine if further pharmacotherapy isneeded.These tools were integrated into a single booklet, including a policy for detoxification and an

integratedcarepathway(ICP)inwhichnurseswereenabledtoadministerchlordiazepoxide,withthedose dependent on the symptom score. A steering group engaged with hospital directorates andgainedapproval.Plans forhospital-wide implementationwereput intoplace,which includedemailalertstoallconsultants,alcohollinknursesandalliedhealthprofessionals.Therewerealsoadvertisingposters,andarticlesintrustmagazinesandonnoticeboards.Before implementation,80hour-long,separateteachingsessionsweredeliveredbythealcoholteamovera2-weekperiodtoall appropriate clinical staff. Implementation followed, assisted by a timely changeover of juniordoctorsandbyconstantencouragementandendorsementoftheICPbythealcoholteamPost-interventionauditApost-interventionaudit tookplace4monthsafter the implementationof thepolicyand ICP.Thesamemethodandaudittoolwereusedtoobtaindata.Thesamplegroupwasthesamesizeastheinitial sample, recruitedasconsecutivepatientsand fulfilling thesamecriteria.A staff-satisfactionquestionnairewasalsousedtogaininsightintoclinicians’thoughtsonthenewpolicyandICP.Amixofopenandclosedquestions,sentto300clinicalstaff,obtainedqualitative findings.ResultsResultsofpre-implementationauditTheaveragenumberofdaystodetoxapatientwas6.36.Onaverageitcosts£300pernightforaninpatientstay,makingtheaveragecostofthesedetoxattempts£1908.Theaveragedoseofchlordiazepoxidetocompleteaninpatientdetoxwas563.3mg.FortypercentofpatientsweregivenPRN(whenrequired)medication,butinonly10%ofthese(twopatients)wasthereasondocumented.Sixoftheprescriptionsdidnotusechlordiazepoxidebutothermedication.Therewereanumberofprescribingerrors,suchas:

§ Dosingregimensprescribedinthewrongareaofprescriptionchart§ Nomaximaldoseenteredon chart§ Taperingdosesthatincreasedinsteadofdecreased§ Prescriptionsthathadfixeddosesforanumberofdaysinsteadofdecreasing§ OnlyPRNmedicationwritten,withnoguidanceonadministration§ Four prescriptions had fixed dosing, so there was no reduction, which is needed in

withdrawaltreatment.Therewasgreatvariationintheprescribingmethodsusedwhenreducingchlordiazepoxideandinthe

numberofdaystocompleteadetox(4to10).Mostimportantly,atotalof11patientsdevelopedsignsofsevereAWS:5developeddeliriumtremensand6hadpost-admissionseizures.Results of post-implementation audit The average number of days to complete detox afterimplementationoftheICPwas2.48.Onaverageitcosts£300pernightforaninpatientstay,makingtheaverage costofthesedetoxattempts£744.Theaveragedoseofchlordiazepoxidetocompleteaninpatientdetoxwas167.2mg.Chlordiazepoxidewastheonlydrugused.Fivepatientsrequirednochlordiazepoxide.

WiththeCIWA-arscoringchart,itwasclearwhatsymptomsthepatientwasdisplaying.Thenursecould then administer a dose of chlordiazepoxide as required to alleviate the symptoms.Documentationhadimprovedbecausenowallclinicianswereusingthesamepaperworktomanagethis patient group. Use of the CIWA-ar also identified exactly what symptoms the patient wasdisplaying.

Before the project, 11 people from the sample group developed severe signs of AWS suchasseizuresordeliriumtremens.Followingthechange,nopatientdevelopedseveresignsofAWS.Clearly,this isonly for this sampleand a larger studywould have to be done to ensure this finding wasaccurate. However, in light of the theory behind the symptom-triggered approach, identifyingsymptomsearlyshouldpreventexacerbation.Allprescriptionswerewrittencorrectlyandthedoseofadministrationwasonlywrongonthree

occasions,withpatientsnothaving the right amount in accordancewith their CIWA-ar score.Thiswasputdowntonursingerror,astheflowcharthadnotbeenfollowedcorrectlyandthistriggeredfurthereducational input (refresher sessions for individual nursesweregivenwhere needed). NopatientsfromthissamplegroupdevelopedsignsofdeliriumorseizuresafterstartingtheICP.

A totalof212questionnaireswerereturnedbyafullrangeofclinicalstaff,fromconsultant to staffnurse, 97% of whom believed that the ICPwasuser-friendly.Thevastmajority(98%) believed thatthere had been improvements in care for this patient group, and that detox was achievedmuchquickerandwasofbenefitbothtothem(throughreducedworkload)andtothepatientsthemselves.From the questionnaires, theprojectteamconcludedthatcliniciansweresatisfiedwiththechange,mostlybecauseof the benefits for patients.The results identified that an increase in satisfactioncorrelateddirectlywiththeincreaseincompliance.It was hypothesised at the start of the project that the use of an evidence-based, symptom-

triggered,individualisedapproachtowithdrawalmanagement,ifusedinanacutesetting,wouldimprovepatientcare. It was thought that theamountofchlordiazepoxideadministeredwoulddecrease,resultinginashortertreatmentduration.TheseresultswereconfirmedbytheMann-Whitneynon-parametric statistical test. This testwas chosen because therewasno specific distribution for thepopulation,resultinginskeweddata.ThestatisticswereanalysedwithSTATAsoftwareandresultedinapvalueof0.001(p=0.001).Thiswasthecaseforbothdurationoftreatmentandtheamountofchlordiazepoxideadministered,therebyconfirmingthehypothesis.DiscussionTheresultsofthepre-andpost-implementationauditaccordswithfindingsfrompreviousresearchersonthissubject(Sullivanetal,1989;Daeppenetal,2002;Dayetal,2004;Saitzetal,2004).Thesampleswerenot case-controlled,which somemightargueundermines theconclusions.Yetthe resultsaretoo startling to be the result of coincidence (the statistical analysis showed that the likelihood ofthembeingacoincidenceisjust0.01%).Figure5showsthat the time forapatientto completeadetoxhasbeengreatlyreducedsince the

implementationoftheICP.Furthermore,theamountofchlordiazepoxideneededtocompleteadetoxhasalsofallensignificantly(Figure6).Even though significantly less chlordiazepoxidewas required in themajority of cases tomanageAWS,notonepersonfromthissamplegroupdevelopedseveresignsofwithdrawal. It ismost likelythat this isdue to thepatientsbeingassessedmorefrequentlywithavalidatedassessmenttool,inconjunctionwithstaffhavinganincreasedknowledgeofthewithdrawalprocess. Italsoprovidesanindividualisedtreatmentplan.Thefactthatsignsandsymptomswerebeingdetectedearlierensuredthat patients were adequately medicated and autonomic responses were kept to a minimum,safeguardingagainst thedevelopmentofsevereAWS.As a contained booklet, itwas clear that the ICPwasallowingstafftoensuredocumentationwas

correctandactingasaguide toguarantee thatstaffknewexactlywhentoassessandmanagethelevelofwithdrawaltheywerepresentedwith.Documentationasawholehadimproved.TheCIWA-arscore meant that staff identified individual symptoms of withdrawal instead of using broadterminolgyandgrouping.

Iftheseresultsaretranslatedintoevenveryroughcostings,thesavingstothetrustareobvious.Pre-implementation, the average cost of an inpatient stay for detoxification was £1908. Post-implementation,thisfell to£744. More importantly, fewer drugs were used.These drugswere appropriate in all cases and noseveresymptomsoccuredinanyofthepatientsfromtheauditsample.

Implementation was not without its problems, however, and a key stage was the arrival of newdoctorsinthetrust,whichreallymovedthechangeforward.Thepolicywasnotachangeinpracticeforthesenewdoctors,whoaccepteditastrustpolicyandbegantouseit.Toanextent,then,theydrovetherestoftheclinicalteamtousetheICPandmovethecareofthispatientgroupforward.Fromthepointofviewof the alcohol team,whichhadspentahugeamountof timeandenergyeducating and implementing the policy, the surge in referrals was a validation of its efforts. Theincreaseincompliancemeantmorepatientswerebeingassessedbyanalcoholspecialist,resultinginin-depthalcoholhistories,appropriatetreatmentoptions,prompterdischargesand,whenrequired,moresuccessfuldetoxattempts.Thealcoholteamwasalsoidentifyingtrends:forexample,itnotedearlyonthatnotallpatientswhowerealcohol-dependentshowedphysicalsignsofwithdrawalandrequiredmedication to stop. Beforemoving to the symptom-triggered approach tomanagement,patients wouldhave automatically been started on a prophylactic detox regime and could be inhospital forupto10daystocomplete it,eventhoughtheirbodiesdidnotrequireanymedication.Somepeoplewerecompletingdetoxinas little as2days.Both these lastpoints showednurses that, if lookedafterappropriately,thepatientsrequired less

management overall and spent less time in hospital. The alcohol team was also getting fewercomplaintsfromitspatientswithregardtotreatment,duetotheirdetoxbeingmanagedappropriately.Anearly referral to thealcohol teamshowedpatients that the hospital was trying tohelp them—theirstay wasmuchmorethanjusthavingpillsfourtimesadayandtheyhadpropertreatmentplansandaftercareorganised.Theteam’scredibilitygrewwithinthehospitalduetoimprovedpatientcare.Clinicianscouldseethat

the ICP was indeed improving care, improving documentation, improving patient satisfaction andreducingclinicalincidents.Thesethoughtswerereinforcedwiththeresultsofthepost-changeaudit.ConclusionThisprojecthasachievedwhatitsetouttoachieve:anevidence-basedintegratedcarepathwayforagroupofpatientsforwhomcarehadbeenlessthanoptimal,resultinginrepeateddetoxificationandpooroutcomes.Thecostsavings,bothintermsofinpatientstayanddruguse,arequantifiable.Thepotentialbenefitsoffewerrepeatepisodesofdetoxificationandtherevolving-dooreffect,aswellasthegreaterpatientsatisfaction,arelesseasytoquantify,butdoingsoremainsanaimforfuturework.Excessive drinking is currently the second greatest risk to public health in developed countries

(Kaner,2010).Althoughmost of that risk is avoidable, the risk is clearly apparent with the largenumberofhospitaladmissionseveryyear.Asmanyasone in threeA&Eattendeeshaveconsumedalcoholimmediatelybeforetheirpresentationandmorethantwointhreeentriesaftermidnightmaybealcoholrelated(Williamsetal,2005).The focusonalcohol isbecomingmoreapparent. Initiatives suchas theCommissioning for Qualityand Innovation (CQUIN) payment framework enable commissioners to reward excellence bylinkingaproportionofhealthcareincometotheachievementofthelocalqualityimprovementgoals.Thefactthatalcoholissuchamajorproblemforpatients,butisalsonowlinkedtofinancialgainfortrusts, makes it even more imperative that treatment is timely and effective. This projectdemonstratesonesuchmethod.

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Key Points

n DespiteanincreasingawarenessofitsdangersalcoholremainsaseriousandgrowingpublichealthconcernintheUK

n Alcohol-relatedadmissionsaresteadilyrisingandalthoughalcoholmisuseiscommonamonggeneralinpatientsmanyareinadequatelyassessedandtreatedforalcoholwithdrawal

n Thisprojectlookedatwaysofimprovingthemanagementofpatientswithdrawingfromalcoholandchangedpractice

n A‘symptom-triggered’approachtomanagingwithdrawalsymptomsinanacutehospitalsettingisachievableandcanimproveoutcomesforpatients,andreducetreatmentdurationandtheamountofmedicationused

n Alcoholmisuseshouldbeahighpriorityoneveryhospitaltrust’sagenda—projectssuchasthisonecanimprovepatientexperienceandstaffawareness

Box 1. Audit tool and rationale for questions Was the alcohol ICP used in the management of this patient? Importanttoidentifyifthetrustguidelinesarebeingmet

Number of days to complete detox? Importanttocomparepre-ICPandpost-ICPtonoteanyimprovement

How much chlordiazepoxide was administered? Importanttocomparepre-ICPandpost-ICPtonoteanyimprovement

If ICP not started, was PRN medication used? Thiswillidentifyifpredetermineddosingregimesareusedandwhetherstaffaretryingtoalleviatefurthersymptomswithas-requiredmedication

If PRN medication was used, was the reason identified in the notes? ThiswillhighlighttheneedforCIWAscoringsystemthatispartofICPtoimproveassessmentanddocumentation

What drug is used in the detox process? Willseeifweareusingthebestavailablepharmacologytomanagethisgroup

Is there consistency with prescribing? Arethemedicinesprescribedinproperplace?

Are all areas of the prescription chart complete? Thiswillidentifyanyproblemswithmedicalprescribing

Did anyone develop delirium or seizure activity after starting on a detox? Thiswillhelpidentifydifferencesbetweensymptom-triggeredmanagementandpredetermineddosing

inneurotransmissionsinthebrain(McKinley,2005).Thechronicpresenceofalcoholonthebrainleadstoneuroadaptationandaffectsbrainreceptorsbecausethebraintriestomaintainahomeostaticbalance(HoffmanandTabakoff,1996;Amatoetal,2010). Neurotransmitters transmit information between neurons via synapses,eitherexcitingorinhibitingimpulsesalongtheneurons(McKinley,2005).Alcoholactsasanantagonistatkeyreceptors—someof thekeychanges involvereducedbraingamma-aminobutyric acid (GABA) levelsand GABA-receptor sensitivity (GoldandAronson,2011).Prolongedintakecausesadjustmentofthecentralnervoussystem,reducing the initial short-term effects (McKinley, 2005). Abrupt cessation orwithdrawal of alcohol intake causes a rebound stimulatory effect, resulting inautonomichyperactivity,leadingtosymptomsofAWS(McKinley,2005).It is important to treat AWS in order to decrease the severity of symptoms,

preventingmore severe alcoholwithdrawal phenomena such as seizures, deliriumtremens and Wernicke’s encephalopathy, which can be fatal. The advances inknowledgeofneurobiologyandneurochemistryhavepromptedtheuseofdrugsinthe treatment of alcohol dependence and withdrawal that will allow the GABApathwaystorestorenormalbrainfunction(Amatoetal,2010).Thereisavarietyofdifferingmedications thatworkon theGABAneurotransmitters in the brain totreatAWS(Amatoetal,2010;NationalInstituteforHealthandCareExcellence(NICE),2010a)and the trust’s alcohol steering group decided to develop a protocol based onbenzodiazepines, which are widely recognised as the drug of choice fordetoxification(Daeppenetal,2002; Asplundetal,2004;Saitzetal,2004;McKinley,2005;Amatoetal,2010;NICE,2010a).Benzodiazepines relieve the symptoms of alcohol withdrawal and reduce the

frequencyofseizuresanddeliriumtremens(Saitzetal,2004)byactingontheGABAreceptors and thus stopping the autonomic responses that follow cessation ofalcohol(Asplundetal,2004;McKinley,2005;NICE,2010a).Whenadministered appropriately, benzodiazepines will not only prohibit thedevelopmentofAWSbutalsonormalisebrainfunction(Amatoetal,2010).insomnia,nauseaorvomiting,transientvisual,tactileorauditorythepresenceof

alcoholtolerance,thepresenceofanalcoholwithdrawalsyndromewhendrinking

hasceasedorbeenreduced(i.e.physicaldependenceonalcohol),theintakeof

alcoholtorelievesignsofwithdrawal,andthepresenceofdifficultiesincontrolling

drinking,withastrongdesireorcompulsiontodrink(HoffmanandTabakoff1996).

ThenumberofdependentdrinkersinEnglandnowstandsat1.6million(Alcohol

Concern2010).ThecosttotheNHSis2.7billionpoundseveryyearandisexpected

tocontinuetoriseto3.7billion(AlcoholConcern2010).Althoughalcoholuseand

abusearecommonamonggeneralhospitalinpatients,manypatientsare

inadequatelyassessedandtreatedforalcoholwithdrawal(Repper-Delisi2008).

AlcoholWithdrawalSyndrome(AWS)isaclusterofsymptomsthatmaydevelopin

alcoholdependentpeopleafterthecessationof(orreductionin)heavyand

prolongedalcoholuse(AmericanPsychiatricAssociation2000).Theclinical

presentationvariesfrommildtoseriousandtheonsetofsymptomstypicallyappear

uptoforty-eighthoursafterthelastconsumptionofalcohol,andactuallyupto

seventy-twohoursifweconsidertheuncommoncaseofdeliriumtremens(Amatoet

al2011).Deliriumtremenshappensonlyinabout5%ofpatientsundergoingalcohol

withdrawalhoweverhasthehighestmortalityrate(5to20%ininappropriately

managedpatients),itisamedicalemergencyandisanadvancedstateofautonomic

hyperactivity.Thereissubstantialindividualvariationintheclinicalmanifestationsof

alcoholwithdrawal,rangingfromverymildtremorandirritabilitytosignificant

autonomichyperactivity(e.g.sweatingorpulserategreaterthanonehundred)

(Amatoetal2011,Wetterlingetal2001,HoffmanandTabakoff1996).DSM-IV

continuesthesymptomlistwiththefollowingsymptoms;tremor,insomnia,nausea

orvomiting,transientvisual,tactileorauditoryhallucinationsorillusions,

psychomotoragitation,anxietyandseizures(AmericanPsychiatricAssociation2000).

TodefineAWS,thepatientmusthavetwoormoreofthesesymptomsfollowing

cessationorreductionofalcohol(McKeon2008).

Ingeneralhospitals,alcoholwithdrawaloftencausessignificantmanagement

problemsandcomplicatesthemanagementofawidevarietyofconcurrent

conditions(Foyetal1997).ThisplacesahugeburdenontheNationalHealthService

(NHS).AlcoholConcern’s(2011)researchshowedthatthenumberofhospital

admissionswas1.1millionin2009/2010,a100%increasesince2002/03.

Thealcoholspecialistnursesnotedthattheytendedtobeapproachedtoconsulton

alcoholdetoxificationonlywhenthingswentslightly‘wrong’andwereworried,

aboutalackofeducationinallcliniciansarounddetoxificationandalackofevidence

basedprotocolstoassistinpatientcare.Asignificantnumberofcriticalincidents

aroundpatientswhowereundergoingdetoxificationaddedtotheledtotheneedfor

aprojecttoimplementandevaluateanevidencebasedapproachtothe

managementofalcoholdetoxification.

TheProject

Theprojectconsistedofthreephases

• apreinterventioncasenoteauditlookingatthemethodofdetoxification,the

drugsusedandthetimetaken

• thedevelopmentofanevidencebasedprotocolforthemanagementof

detoxificationalongwiththeeducationofstaffandtheimplementationof

theprotocol

• apostinterventioncasenoteaudit

Thepreinterventionaudit

Asampleoffiftypatientcasenoteswereanalysedinthepre-changeaudit.Itwasfelt

thissizewouldhighlighttrendsinthetotalpopulationandwasasufficientenough

sizetoextractadequatefindings.Thiswasaconveniencesampleusingthefirstfifty

patientswhowerereferredtothealcoholservicewhohadthatcompletedadetoxas

aninpatient.AllpatientshadtofittheICD10classificationsofalcoholdependency.

Thefindingsgatheredfromthisweretakeninaquantitativeformat,thiswasfelt

appropriatetomakesmoothercomparisonswiththepost-changeaudittocomplete

theauditcycle.Themedicalrecordsofthesepatientsweremanuallysearchedto

obtainthedataneededinaccordancewiththeaudittool.

Figure1

AuditTool

1. WasthealcoholICPusedinthemanagementofthispatient?

ImportanttoidentifyiftheTrustguidelinesarebeingmet

2. Numberofdaystocompletedetox?

ImportanttocomparepreICPandpostICPtonoteanyimprovement

3. HowmuchChlordiazepoxidewasadministered?

ImportanttocomparepreICPandpostICPtonoteanyimprovement

4. IfICPnotcommenced.WasPRNmedicationutilised?

Thiswillidentifyifpredetermineddosingregimesareusedarestafftryingto

alleviatefurthersymptomswithasrequiredmedication

5. IfPRNmedicationwasusedwasitidentifiedinthenoteswhy?

ThiswillhighlighttheneedforCIWAscoringsystemthatispartofICPtoimprove

assessmentanddocumentation

6. Whatdrugisusedinthedetoxprocess?

Willseeifweareusingthebestavailablepharmacologytomanagethisgroup

7. Isthereconsistencywithprescribing?

Thiswillidentifyanyproblemswithmedicalprescribing.Arethemedicines

prescribedinproperplace?AreallareasofKardexcomplete?

8. Didanyonedevelopdeliriumorseizureactivityfollowingcommencementon

adetox?

Thiswillhelpidentifydifferencesbetweensymptom-triggeredmanagementand

predetermineddosing.

Developmentofthetool,educationandimplementation

Theinterrelationshipbetweenalcoholintoxication,dependence,toleranceand

withdrawalarenotfullycomprehended,butaclearrelationshipexistsbetween

alcoholandalterationsinneurotransmissionsinthebrain(McKinley2005).The

chronicpresenceofalcoholonthebrainleadstoneuroadaptationandaffectsbrain

receptorsduetothebraintryingtoattempttomaintainahomeostaticbalance

(Amatoetal2011,HoffmanandTabakoff1996).Neurotransmitterstransmit

informationbetweenneuronsviasynapses.Theyeitherexciteorinhibitimpulses

alongtheneurons(McKinley2005).Alcoholactsasanantagonistatkeyreceptors,

someofthekeychangesinvolvereducedbraingamma-aminobutyricacid(GABA)

levelsandGABA-receptorsensitivity(GoldandAronson2011).GABAallowsmore

chloridetoentertheneuron,makingthedepolarisationofneuronalcellmembranes

lesslikelytherebyinhibitingthecell(McKinley2005).McKinley(2005)alsodescribes

thesecondimportantneurotransmitteraffectedbychronicalcoholabusethatisthe

excitatoryneurotransmitterN-methyl-D-aspartate(NMDA).NMDAregulatesneuron

excitability,increasingdepolarisationoftheneuronalmembranebyregulatingthe

flowofcalciumintotheneuron.ChronicalcoholmisuseresultsinadecreaseinGABA

inhibitoryfunctionandanincreaseinNMDAsensitivity(Amatoetal2011).

Prolongedintakecausesadjustmentofthecentralnervoussystem(CNS),reducing

theinitialshorttermaffects(McKinley2005).Abruptcessationofintakeofalcohol

orwithdrawalcausesareboundstimulatoryeffect,resultinginautonomic

hyperactivity,leadingtosymptomsofAWS(McKinley2005)See(Figure1.).Itis

importanttotreatAWSinordertodecreasetheseverityofsymptoms,preventing

moreseverealcoholwithdrawalphenomenasuchasseizures,deliriumtremensand

WE,whichcouldprovefatal.Theadvancesinknowledgeofneurobiologyand

neurochemistryhavepromptedtheuseofdrugsinthetreatmentofalcohol

dependenceandwithdrawalthatwillallowtheGABApathwaystorestorenormal

brainfunction(Amatoetal2010).Thereareavarietyofdifferingmedicationsthat

workontheGABAneurotransmittersinthebraintotreatAWS(Amatoetal2011and

NICE2010).ThesedrugsincludebenzodiazepineGABAergicmedications,which

consistsofmainlybenzodiazepineandnon-benzodiazepine,GABAergiccompounds,

whichinvolvecarbamazepine,gabapentin,valproicacid,topiramate,Gama-

hydroxybutyricacid(GHB),baclofen,flumazenilandmanymorebesides(Amatoetal

2011).

ItwasdecidedtodevelopaprotocolbasedonBenzodiazepinesthatarewidely

recognisedasthedrugofchoicefordetoxification(Saitzetal(2011),Amatoetal

(2010),NICE(2010),McKinley(2005),Chadetal(2004)andDaeppenetal(2002)).

Benzodiazepinesamelioratethesymptomsofalcoholwithdrawalandreducethe

frequencyofseizuresanddeliriumtremens(Saitzetal2011).Metabolicandcellular

changesdonotresolvewithcessationofdrinking(McKinley2005).Duetothe

changesinthishomeostaticbalanceofthebrainincreasedautonomicresponse

developsinsomepatientspresentingitselfintheformofAWS.Thisiswhy

BenzodiazepinesarerequiredtoactontheGABAreceptorsmirroringthewayalcohol

doesstoppingautonomicresponsesnotedfollowingcessationfromalcohol(NICE

2010,McKinley2005andChad2004).Whenadministeredappropriately

BenzodiazepineswillnotonlyprohibitthedevelopmentofAWSbutbyworkingon

theGABAreceptorswillnormalisebrainfunction(Amatoetal2010).

Chlordiazepoxideismoretypicallyusedinpractice(NICE2010b)wasthereforethe

drugofchoicefortheprotocolhoweverDiazepamandLorazepamcanbeequally

efficacious(Chadetal2004).

Althoughwithdrawalseverityvariesgreatly,andtheamountofmedicationneeded

tocontrolsymptomscanalsovarysignificantlyChlordiazepoxideisusually

administeredinpredeterminedprophylacticdosingschedulesvaryingbetweenthree

andtendays(Saitzetal2011,NICE2010b,McKinley2005,Daeppenetal2002and

McGregoretal2002).Althoughthismethodisusedfrequentlythroughouthospitals,

predeterminedfixeddosingregimesmaysubjectmanypatientstounnecessary

medication,oversedationandlongerhospitalstays(Saitzetal2011,NICE2010,NICE

2010b,HardernandPage2005,Chadetal2004andMcGregoretal2002).Saitzetal

(2011),statesthatmanypatientsactuallyundergoalcoholwithdrawalsafelyand

comfortablywithoutpharmacologicintervention.

Itisclearthenthatamoreindividualisedapproachtomanagementwouldbenefit

patients.Symptom-triggeredtherapy,whichconsistsofmonitoringpatientsand

providingmedicationonlywhensymptomsofalcoholwithdrawalappearisan

alternativeandcouldindividualiseandimprovethemanagementofalcohol

withdrawal(Saitzetal2011andNICE2010b).Anumberofstudieshave

demonstrateditssuccessfuluse(Daeppenetal(2002)Dayetal(2004)Hardernand

Page2005,)anditisrecommendedbyNICE(2010)

Symptomscanbeidentifiedbytheuseofavalidatedassessmenttool.Aquickand

usefulassessmenttoolistherevisedClinicalInstituteofWithdrawalassessment

Scale(CIWA-ar)(McKeon2008).Thisten-itemscalescorestheseverityofnausea,

sweating,agitation,headache,anxiety,tremor,sensorydisturbancesandorientation

(McKeon2008).Sullivanetal(1989)statecompetentnursescancarryoutan

evaluationinlessthantwominutesandtheinter-raterreliabilityishigh.Repeated

scoringatsuitableintervalsdependingonscoringmonitorstheresponseto

treatmentandhelpstodetermineiffurtherpharmacotherapyisneeded.

Usingprojectmanagementmethodologyandutilisingasteeringgroupof

stakeholderswithintheTrust,apolicyfordetoxificationwithanintegratedcare

pathwayasanintegralpartofit.Hswasapprovedbyallgoverningboardsofall

directoratesaspatientsmightbedetoxifyinginanyTrustclinicalareaanditwas

crucialthatallareasusedthepolicy.Thisagreementwasreachedandplansfor

hospitalwideimplementationputintoplacewhichincludedemailalertstoall

consultants,alcohollinknurses,andalliedhealthprofessionalsforcascadingto

teamsaswellasadvertisingpostersandarticlesinTrustmagazinesandonnotice

boards.Priortoimplementation,eighty,hourslong,separateteachingsessionswere

deliveredwithinatwoweekperiod

Theperiodafterimplementationdayandtheweeksafterwerespentchasingdoctors

tochangeprescriptionsfromtaperingprophylacticdosestothesymptom-triggered

approachadvocatedbythepolicy,trainingmoreandmorestaff,andquestioningwhy

nurseswhowereawareofthePolicywerestilladministeringmedicationtheoldway.

Itwasclearnomatterhowrigorouspropagandaisthereisstillahugeproportionof

staffwhoapparentlyhaveneverseenitorindeedencounteredamemberofthe

alcoholteam,alinknurseortheirwardmanagerintheweeksbeforeits

implementation.Overaperiodofweeksthough,thealcoholteamnoticedachange

inpracticeandmoreimplementationofthepolicyandICPandthiswashelped

hugelybythechangeoverofjuniordoctorsinAugust.Theydidnotneedtochange

practice,justtobetoldaboutTrustpolicyandthisheraldedastepchangeinpractice.

DoctorsbegantousetheICPandasknursestoimplementit,asamatterofnormal

practice.

Thepostinterventionaudit

Tocompetetheauditcycle,theauthorcompletedapost-changeauditfourmonths

aftertheimplementationofanalcoholwithdrawalpolicyandICP.Thesamemethod

andaudittoolwasusedtoobtaindata.Howeverthesamplegroupweredifferent

patients,althoughallmetthesamecriteriaaspre-changeauditandthesamplesize

wasthesame.Astaffsatisfactionquestionnairewasalsobeusedtogaininsightinto

clinician’sthoughtsonthenewpolicyandICP.Amixtureofopenandclosed

questionswereutilisedtogatherqualitativefindings.

Resultsofpreimplementationaudit

• AverageNumberofdaystodetoxapatientwas6.36days.

• Onaverageitcosts£300pernightforinpatientstaythereforetheaverage

costofthesedetoxattemptsis£1,908.

•

• AveragenumberofmilligramsofChlordiazepoxidetocompleteaninpatient

detoxwas563.3mg.40%weregivenPRNmedicationbutinonly10%ofthese

(2cases)wasthereasonforthisdocumented

• SixoftheprescriptionsdidnotuseChlordiazepoxidebutusedother

medication.

Therewereanumberofprescribingerrorsmadesuchas:-

• Dosingregimesprescribedinthewrongareaofprescriptionchart

• Nomaximumdoseenteredonchart

• Taperingdosesthatincreasedinsteadofreducing

• Prescriptionsthathadfixeddosesforanumberofdaysinsteadofreducing

• OnlyPRNmedicationwrittenwithnoguidanceonadministration

• 4prescriptionshadfixeddosingsotherewasnoreductionwhichisneededin

withdrawaltreatment

• LargeamountofvariationnotedwhenreducingChlordiazepoxide

• Daystocompleteadetoxrangedfromfourtotendays

Mostimportantly,ElevenpatientsdevelopedsignsofsevereAWS.Fivedeveloped

the‘DeliriumTremens’andsixhadseizurespostadmission.

Resultsofpostimplementationaudit

• Averagenumberofdaystocompletedetoxis2.48days

• Onaverageitcosts£300pernightforinpatientstaythereforetheaverage

costofthesedetoxattemptsis£744.

• AveragenumberofmilligramsofChlordiazepoxidetocompleteaninpatient

detoxwas167.2mg.

• Chlordiazepoxidewastheonlydrugused

5patientsrequirednoChlordiazepoxide

ItcanbenotedthatwiththeuseoftheCIWA-arscoringchartitwasclearwhat

symptomsthepatientwasshowing.WiththisthenursecouldprescribeX-amount

ofChlordiazepoxideasrequiredtoalleviatethesymptoms.Documentationhad

improvedbecausenowallclinicianswereusingthesamepaperworktomanagethis

patientgroup.

AllprescriptionswerewrittencorrectlyasperICP.Thedoseofadministrationwas

onlywrongonthreeoccasionswithpatientsnothavingtherightamountin

accordancetotheirCIWA-arscore.Thiswasputdowntonursingerror,astheyhad

notfollowedtheflowchartcorrectly.

Nopatientsfromthissamplegroupdevelopedsignsofdeliriumorseizurespost

commencementontheICP.

212questionnaires,consistingofamixtureofclosedadopenendedquestionswere

returnedbyafullrangeofstafffromconsultanttostaffnurse,97%ofwhomfeltthat

theICPwasuserfriendly.98%feltthattherehadbeenimprovementsincareforthis

patientgroupandfeltthatdetoxwasnomuchquickerandwasofbenefitbothto

workloadandtothepatientthemselves.

Discussion

Theresultsoftheauthor’sauditcyclemirrorpreviousresearchDaeppenetal(2002),

Dayetal(2004),HardenandPage(2005)andSaitzetal(2011).Althoughflawscan

benotedinalltheresearchandhere,becausethetwogroupscontaindifferent

patientsandthesampleisnotcasecontrolled,thismightbefelttodamageany

claimsmade,theresultsaretoostartlingtobetheresultofcoincidence.

Thecomparitivegraphisaclearindicatorthatthetimeforapatienttocompletea

detoxhasgreatlybeenreducedsincetheimplemetnationoftheICP.Furthermore,

theamountofChlordiazepoxidetosuccesfullycompleteadetoxwasalsoshownto

decreasesignificantly.

EventhoughlessChlordiazepoxidewasrequiredinthemajorityofcasestomanage

AWS,notonepersonfromthissamplegroupdevelopedseveresignsofwithdrawal.

Itismostlikelythatthisisduetothepatientsbeingassessedmorefrequentlyusinga

validatedassessmenttoolinconjunctionwithstaffhavinganincreasedknowledgeof

thewithdrawalprocessthabeforetheintroductionoftheICP.Thefactthatsigns

andsymptomswerebeingdetectedearlier,ensuredpatientswereadequetly

medicatedandautonomicresponseswerekepttoaminimumsafeguardingagainst

thedevelopmentofsevereAWS.

ItwasclearthattheICPasacontainedbookletwasallowingstafftoensure

documentationwascorrectitwasactingasaguidetoguaranteestaffknewexactly

whentoassessandhowtomanagethelevelofwithdrawaltheywerepresented

with.

Iftheseresultsaretranslatedintoevenveryroughcostings,thesavingstotheTrust

areobvious.Preimplementation,theaveragecostofaninpatientstayfor

detoxificationwas£1,908.Postimplementationthisreducedto£744.More

importantly,lessdrugswereused,appropriatedrugswereusedinallcasesandno

severesymptomsdisplayedbyanyofthepatientsfromtheauditsample,whichwas,

asinthepreimplementationaudit,asetof50consecutivereferralstotheservice.

Implementationwasnotwithoutitsproblemshoweverandakeystagewastheentry

ofnewjuniordoctorstotheTrustwhichreallymovethechangeforward.Thepolicy

wasnotachangeinpracticeforthesedoctorswhoaccepteditasTrustpolicyand

begantouseit,thus,toanextent,forcingtherestoftheclinicalteamtousetheICP

andmovepracticeandthecareofthispatientgroup,forward.

Forthepointofviewofthealcoholteamwhohadspendanhugeamountoftimeand

energyeducatingandimplementingthepolicy,thesurgeinreferralswasavalidation

oftheirefforts.Withtheincreaseincompliancecametheincreaseofsupportfrom

alcoholservices,withtheteam’searlyinputandsupportensuredthatafullalcohol

historywasobtainedandmotivationassessedleadingtoprompterdischargesor

moresuccessfuldetoxattempts.Thealcoholteamwerealsoidentifyingtrendsitwas

notedearlyonthatnotallpatientswhoarealcoholdependentshowactualphysical

signsofwithdrawalandrequirenomedicationtostop.Beforemovingtothe

symptomtriggeredapproachtomanagementpatientswouldhaveautomatically

beencommencedonaprophylacticdetoxregimeandcouldbeinhospitalforupto

tendaystocompleteiteventhoughtheirbodiesdidnotrequireanymedication.

Somepeoplewerecompletingdetoxinaslittleastwodays.Bothoftheselastpoints

wereshowingnursesthatiflookedafterappropriatelythepatientsinthelongrun

requiredlessmanagementandspentlesstimeinhospital.Thealcoholteamwere

alsohavingfewercomplaintsfromtheirpatientswithregardstotreatment.Dueto

theirwithdrawalsbeingmanagedappropriatelyandbeingreferredtothealcohol

teampromptlyshowedthatthehospitalwastryingtohelpthem,theirstaywas

muchmorethanjusthavingpillsfourtimesadaytheyhadpropertreatmentplans

andaftercareorganised.

Theteam’scredibilitywasgrowinginthehospitalandwiththatacceptanceofthe

changefollowed.CliniciansrealisedthattheICPwasindeedimprovingcare,

improvingdocumentation,improvingpatientsatisfactionandreducingclinical

incidentsandthebenefitsofitsusebecameclear,backedupbythesecondaudit

results.

Conclusion

Thisprojecthasachievedwhatitsetouttoachieve;anevidencebasedintegratedcar

pathwayforagroupofpatientsforwhomcarehadbeenlessthanoptimum,

resultinginrepeateddetoxificationandpooroutcomes.Thebenefitsofthecost

saving,bothintermsofinpatientstayanddrugusearequantifiable,thepotential

benefitsoflessrepeatepisodesofdetoxificationandtherevolvingdooreffect,as

wellasthegreaterpatientsatisfactionarelesseasytoquantitybutthisremainsan

aimforfuturework.

Excessivedrinkingiscurrentlythesecondgreatestrisktopublichealthindeveloped

countries(Kaner2010).Althoughmostofthatriskisavoidabletheriskisclearly

apparentwiththelargenumberofhospitaladmissionseveryyear,withasmanyas

oneinthreeattendeeshavingconsumedalcoholimmediatelybeforetheir

presentationandmorethantwo-thirdsofattendancesaftermidnightmaybealcohol

related(Crawfordetal2004).Theemphasisonalcoholisbecomingmoreapparent

andwithinitiativessuchasCommissioningforQualityandInnovation(CQUIN)

paymentframeworkenablescommissionerstorewardexcellenceby,linkinga

proportionofhealthcareincometotheachievementofthelocalquality

improvementgoals.Thefactthatalcoholissuchamajorproblemandislinkedto

paymentstoTrustsmakesitevenmoreimperativethattreatmentistimelyand

effectiveandthisprojectdemonstratesonesuchmethod.