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

Abstract

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.

Alcohol withdrawal syndrome in ICU patients: Clinical features, management, and outcome predictors

“…However, our data cannot allow conclusions about the effectiveness of specific treatments on patient outcomes, highlighting the need for further trials. Interestingly, a recent study reported that the implementation of a hospital-wide protocol for the management of AWS resulted in significant improvements in quality of care, decreased the need for ICU admission and the rate of intubation, reduced hospital length of stay, and was cost-savings [ 34 ].…”

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

“…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.…”

Outcomes After Implementation of a Benzodiazepine-Sparing Alcohol Withdrawal Order Set in an Integrated Health Care System

“…Nonetheless, the use of protocolized approaches has been recommended and put into practice primarily in academic medical centers . Large-scale outcomes studies including multiple therapies in community-based practice settings remain poorly described …”

“…21 Large-scale outcomes studies including multiple therapies in community-based practice settings remain poorly described. 43 Based on a multidisciplinary collaboration among diverse clinical specialties, the KPNC BZD-S order set contained a bundle of features, including educational information on AWS timing, a severity scale, thiamine dosing, several adjunctive agents, and reduced BZD dosing scales. The use of AWS adjunctive agents increased with a concurrent decrease in use and dose of BZDs.…”