Background: Alcohol use disorder (AUD) has a lifetime prevalence of 29% in the United States and prevalence is higher among military veterans. Discontinuation of alcohol use in patients with AUD presents a risk for alcohol withdrawal syndrome (AWS). A recent retrospective analysis of Veterans Health Administration (VHA) data estimated AWS occurred in 5.8% of inpatient admissions with significant regional variation of incidence. Medical management of AWS is also variable. Benzodiazepines (BZD) are widely considered the standard of care although BZD-sparing approaches are a safe and effective alternative for many patients. Emerging evidence suggests BZD-sparing protocols decrease length of stay (LOS), shorten the duration of symptoms, and promote alcohol abstinence compared to BZD.
Purpose: The purpose of this project was to decrease hospital length of stay and benzodiazepine administration without increasing ICU transfer or readmission rates for patients at risk of alcohol withdrawal syndrome.
Description: This project implemented six changes to standardize AWS inpatient management for at risk patients: 1. Patients at risk of AWS are triaged to Medicine services for an observation admission, in the absence of an indication for acute medical, surgical, or psychiatric care2. An electronic medical record (EMR) order set that outlines criteria for the safe use of BZD-sparing medication regimens was disseminated 3. An EMR embedded AWS monitoring tool was deployed which uses the Clinical Institute Withdrawal Scale for Alcohol, revised (CIWA-Ar) and incudes real-time guidance for nurses on BZD administration 4. Blood alcohol content (BAC) estimates and vital signs are incorporated as objective measurements to characterize the risk of complicated AWS5. Medication administration is prompted only if CIWA-Ar > 8, heart rate > 100, and either systolic blood pressure > 160 or diastolic blood pressure > 1006. Nurses are now trained to estimate BAC and avoid medication administration until BAC < 150 mg/dlNew hospital wide policy was implemented August 2019 and 12-month pre/post data for patients at risk of AWS showed:1. Average LOS decreased from 5.76 to 3.92 days (32%)2. Average number of nursing AWS assessments decreased from 12.17 to 9.02 (26%)3. The proportion of patients administered BZD decreased from 61.7% to 45.7%4. The average number of BZD doses required decreased from 5.89 to 3.17 (46%)5. The 30-day all-cause readmission rate did not change from 17.7% 6. The rate of transfer to higher level of care decreased from 4.5% to 2.3%
Conclusions: Inpatient AWS management was standardized, including BZD-sparing medication approaches using the EMR. This was implemented using an electronic order set and an evidence-based monitoring scale. This combination decreased inpatient LOS, conserved nursing resources, and reduced BZD administration without increasing rates of readmission or transfer to higher level of care in a Veterans Affairs hospital. Similar implementation at any hospital with an EMR would be possible through targeted communication and training efforts.