Background: Approximately 5% of patients hospitalized at our institution develop clinically significant alcohol withdrawal syndrome (AWS). Inpatients who develop AWS may experience seizures, delirium, ICU transfer and prolonged length of stay. While the mortality of AWS, mostly related to delirium tremens, has decreased over time, severe alcohol withdrawal is still associated with a mortality of 1-4%. Given that alcohol use disorder (AUD) has a prevalence of 13.9% in the United States, combined with the significant morbidity and mortality of AWS, it is critically important to have evidence-based protocols in place in the inpatient setting.
Purpose: To implement a protocol that makes it easier to provide evidence-based, safe, high quality care to patients with AUD.
Description: A multidisciplinary work group formed in January 2021 to update the existing inpatient alcohol withdrawal order set in EPIC as a quality improvement project. The new order set was implemented in May 2022 at the academic medical center and at all other hospitals affiliated with the institution. The American Society of Addiction Medicine (ASAM) Clinical Practice Guideline on Alcohol Withdrawal Management states that preventative pharmacotherapy should be prescribed for patients at risk of developing severe or complicated withdrawal. Prior to updating the order set, pharmacotherapy options for AWS were limited to symptom-triggered benzodiazepines. While benzodiazepines dosed via CIWA-Ar protocol is considered the standard of care for mild-to-moderate AWS, diazepam is preferred over lorazepam in patients with normal liver function and was only being prescribed to 9.5% of patients. To identify patients at risk for severe withdrawal, the order set instructs providers to use the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), which is highly sensitive and specific for predicting severe withdrawal [1]. For patients with a PAWSS score of 4 or greater phenobarbital can be prescribed, which has been shown to improve treatment outcomes in this group [2]. A scheduled gabapentin protocol is also available for patients, which has been shown to shorten hospitalizations and decrease benzodiazepine exposure [3]. Before implementing the new order set, only 57.9% of patients were referred to social work to receive AODA treatment resources. In the new protocol, social work is automatically consulted to ensure patients are made aware of these resources. Additionally, the new protocol requires social workers to inquire if AWS patients are interested in medications for AUD on discharge and includes channels for communication of this information to the provider. Only 6.3% of patients were prescribed an FDA approved medication for alcohol use disorder to help reduce relapse previously, demonstrating the immense room for improvement in treating these patients following acute withdrawal.
Conclusions: Updating the order set to include preventative pharmacotherapy for patients with elevated PAWSS scores is showing a trend to decrease ICU transfers for worsening withdrawal. Through collaboration with social work more patients with AWS are receiving treatment resources and medications for AUD on discharge. We anticipate that these trends will continue, and perhaps become stronger, as providers at our institution become more familiar with the new order set.