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Abstract

Introduction: Alcohol withdrawal management in hospitalized patients is a challenging problem with implications on patient and staff safety, outcomes and overall cost of hospital stays. Hypothesis: Based on increasing reports of violent behavior and costly cases possibly related to alcohol withdrawal syndrome, our three hospital system formed a multidisciplinary team to optimize the alcohol withdrawal management protocol. The goal was to reduce violent behavior, protect staff, and improve patient outcomes by reducing rapid response team (RRT) calls related to oversedation or respiratory causes. The team also did extensive education to promote the use of the new order set to ensure appropriate monitoring and therapy. Methods: Improvements based on literature review were incorporated into alcohol withdrawal protocol in the electronic health record. The alcohol withdrawal risk screen was updated to include the CAGE questionnaire. The order of symptom assessment for the CIWA-Ar was changed to support symptom driven medication selection. Separate order sets were developed for prevention and treatment of withdrawal. Benzodiazepine treatment options were expanded to include more aggressive dosing schemes for severe acute withdrawal, promoting IV push dosing over continuous infusion benzodiazepines. Antipsychotic dosages were increased and criteria were designated for symptom driven administration. Clonidine was added as a treatment option for adrenergic symptoms. Results: An association was observed between the creation of an evidence based alcohol withdrawal prevention and treatment order set and a decrease in RRT calls. There was a 55.9% relative risk reduction in RRT calls related to oversedation or respiratory cases after implementation of the new protocol. Conclusions: By utilizing literature review and expert opinion, our team identified opportunities to improve the management of alcohol withdrawal by modifying nursing assessments to determine patient risk level and by directing pharmacologic therapy based on symptomatology. The protocol was widely used before and after improvements were made, leading to a decrease in RRT calls.