Implementation of a Symptom-Triggered Benzodiazepine Protocol for Alcohol Withdrawal in Family Medicine Inpatients

Abstract

Purpose The purpose of this pilot study was to review the implementation of symptom-triggered benzodiazepine therapy and evaluate the feasibility and outcomes as compared with a previous hospital standard of fixed-dose phenobarbital protocol for alcohol withdrawal on a family medicine service. Methods This retrospective chart review of 46 patients' medical records was performed on admissions to the family medicine service occurring between February and October of 2005 compared with February and October of 2006. Included in the study were adults who were suffering from alcohol withdrawal symptoms (AWS), who admitted to heavy daily alcohol intake, who were intoxicated on admission, and who had a history of AWS and/or history of AWS-related seizures. The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) was used to evaluate the impact of individualized symptom-triggered therapy on outcome measurements utilizing symptom-triggered benzodiazepine therapy compared with the previous hospital standard using a fixed-dose phenobarbital protocol. Results One hundred percent of the patients in the phenobarbital group required drug compared with 38% in the benzodiazepine group ( P < 0.001). Fewer patients (9.5%) in the benzodiazepine group left the hospital against medical advice (AMA), while 36% of patients in the phenobarbital group left AMA ( P = 0.045). There was no significant difference in length of stay or the number of days on the protocol. Conclusion The results of the pilot study demonstrated that symptom-triggered therapy using benzodiazepines resulted in better outcomes than fixed-dosing phenobarbital. Importantly, most patients in the benzodiazepine group required no drug administration.

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

“…Our experience suggests that a comprehensive, CPOE-based protocol with targeted training may result in significant improvements in outcomes, patient safety, and operational efficiency. Results from this study also lend further support the reduction in the need for ICU-level of care as well as adverse ICU-related outcomes 16, 17, 18…”

Evaluation of the Brief Alcohol Withdrawal Scale Protocol at an Academic Medical Center

“…An additional difference between our study and previous studies is the inclusion of a diverse population of hospitalized patients. The study by Daeppen et al (2002) included only patients entering an alcohol treatment program whereas the other 2 studies (Jaeger et al, 2001;See et al, 2009) included patients admitted to a medicine service. In addition to these studies, a study of patients in a medical ICU with a primary diagnosis of alcohol withdrawal demonstrated a median dose of 74 LEs with a symptom-triggered protocol (Sen et al, 2017).…”

Outcomes after Implementation of an Alcohol Withdrawal Protocol at a Single Institution

“…Despite the decrease in benzodiazepine usage, there was no observed change in LOS for the overall cohort involved in this study, which is consistent with the findings of other studies. 9,12,14 Even though it seems incongruent to decrease benzodiazepine use, yet not affect LOS, it should be noted that this study included a mixed population of psychiatric and nonpsychiatric patients, of whom approximately 40% were admitted primarily for indications other than alcohol withdrawal. Therefore, it is possible that LOS did not change due to the need for medical or psychiatric stabilization unrelated to AWS.…”

“…[11][12][13] The goal was to standardize the treatment of AWS at our facility ( Figure 1). A key component of this protocol was the transition to the use of CIWA-Ar to monitor for AWS, as the protocol called for the administration of diazepam based on nursing assessment of CIWAAr scores.…”

“…After a literature search was performed to identify successful alcohol withdrawal protocols at other institutions, a facility-wide, symptom-based alcohol withdrawal protocol was created by a multidisciplinary committee comprised of physicians, pharmacists, and nurses and was implemented in October 2014. [11][12][13] The goal was to standardize the treatment of AWS at our facility (Figure 1). A key component of this protocol was the transition to the use of CIWA-Ar to monitor for AWS, as the protocol called for the administration of diazepam based on nursing assessment of CIWA-Ar scores.…”