Published in the June 2011 issue of Today’s Hospitalist
MOVING TO STANDARDIZE how doctors identify and treat common conditions has substantially improved out- comes for myocardial infarction and pneumonia. But in the case of alcohol withdrawal syndrome, treatment is all over the map.
St. Francis Hospital and Medical Center in Hartford, Conn., decided to tackle that issue two years ago. The 617-bed center adopted guidelines that address every aspect of alcohol withdrawal syndrome, from recognition and risk stratification to treatment.
Danyal Ibrahim, MD, MSc, CPH, then the newly hired director and chief of medical toxicology, explains that he decided to help craft those guidelines after seeing wide variations in how doctors approached treatment.
"Different providers had different styles, even at the level of nursing," Dr. Ibrahim says. Many physicians put patients with withdrawal-induced agitated delirium on Ativan or lorazepam drips, a sledgehammer approach that led to long stays.
Others consistently under-treated with benzodiazepines and failed to get timely control of agitation. And while some physicians relied exclusively on PRN benzodiazepine dosing, regardless of patient severity, others opted for strict fixed-schedule dosing.
As a result, many patients with alcohol withdrawal “a figure that Dr. Ibrahim estimates is between 5% and 10% of inpatients, regardless of admitting diagnosis “were consistently under- or over-treated. Many also never received the right diagnosis because their risk for a complicated alcohol withdrawal course was never assessed.
"Risk stratification is essential, but it was lacking," Dr. Ibrahim says. "Physicians tend to use the same treatment elements, but in widely varying ways because there isn’t risk stratification from the beginning."
The guidelines put in place, he adds, include "three measures for different categories of risk." Just as physicians wouldn’t treat chest pain in an ostensibly healthy 20-year-old the same way they would a 59-year-old with known heart disease, doctors have to take different approaches to patients at different levels of risk for alcohol withdrawal.
To draft the new guidelines, Dr. Ibrahim helped convene a hospital-wide team that included emergency medicine, patient care services, intensive care medicine, psychiatry, addiction medicine, surgery, hospital medicine, nursing and pharmacy.
One problem was that the published guidelines that Dr. Ibrahim had seen on the inpatient management of alcohol withdrawal had significant shortcomings. Some didn’t adequately address alcohol withdrawal severity, he explains, while others were too rigid. Still others were "so complex and impractical," he points out, "that physicians and nurses probably wouldn’t follow them."
The guidelines the hospital developed call for proactive screening to identify alcohol withdrawal syndrome (or patients at risk for it) early on. It also differentiates among patients at low, moderate or high risk for progressing to a complicated alcohol withdrawal course and agitated delirium.
Who’s considered high risk? Symptomatic patients with a history of agitated delirium or those who present with alcohol withdrawal seizure or one or more major risk factors: hyperadrenergia (temperature of 101 degrees or higher), a heart rate of 115 or greater, systolic blood pressure of 170 or higher, or a major comorbid illness.
Moderate-risk patients have a minor risk factor: history of alcohol withdrawal seizure or heavy alcohol de- pendency (reported daily intake of 20 or more standard drinks, or alcohol withdrawal syndrome symptoms with blood alcohol level of 150 mg/dl or higher). When physicians can’t obtain a history of previous alcohol withdrawal complications, symptom severity guides stratification.
Clinical Institute Withdrawal Assessment (CIWA) alcohol rating scores figure prominently in the guidelines. Patients at low risk, for instance, have neither a minor nor a major risk factor and a CIWA score of 20 or less.
Aggressive interventions and monitoring
Patients’ risk also determines treatment, and the guide- lines call for aggressive drug intervention for agitated patients. The guidelines also rely on frequent CIWA assessment as triggers for adjusting medications. For high-risk patients with either current or impending agitated delirium, the first step is front-loading them with Valium boluses, as frequently as every 10 minutes.
"Our approach is to get the agitation under control on a timely and safe basis within two hours," Dr. Ibrahim says. The biggest flaw with alcohol withdrawal management, he adds, "is that providers don’t do a good job controlling agitation, and it goes on for hours and hours."
Patients receive Valium boluses over the course of two hours until they are calm. While Valium is no longer widely used, Dr. Ibrahim contends that it’s both safe and effective in treating agitation. The physicians at St. Francis use haloperidol only as an adjunct for persisting agitation after the Valium front-loading.
Once patients are calm, they are switched to lorazepam on a taper over five days. "In between, we use PRN dosing, triggered by CIWA changes, if the patient is cooperative and coherent," Dr. Ibrahim notes.
For moderate-risk patients who aren’t at risk for agitated delirium and whose starting CIWA score is less than 20, treatment starts with lorazepam on a scheduled taper, with PRN add-ons triggered by CIWA hikes. Low-risk patients with no history of agitated delirium or risk factors receive lorazepam PRN triggered by CIWA scores.
While some guidelines call for CIWA assessment every two or four hours, Dr. Ibrahim notes, many "don’t address frequency at all." To identify symptom changes and guide medication titration, the guidelines at St. Francis call for CIWA monitoring at 30-minute intervals for patients with scores of 15 or higher. Once the score drops to 15, assessment occurs every hour. (CIWA scoring takes place every four hours when the score dips below 8 for four hours.) If the score continues to be more than 15 for more than two hours, the physician is called.
Dr. Ibrahim admits that the guideline team thought "long and hard" before adopting such aggressive assessment because of the work it created for nurses. "But we ultimately decided that following CIWA scores more frequently with the sicker patient is very powerful," he notes.
"A massive education effort"
Implementing the new guidelines required a massive education effort. All physicians, nurses and nurse educators received mandatory education through lectures and in-services held hospital-wide. Housestaff are educated as well, and the lecture cycle repeats on a monthly basis when new housestaff arrive.
Nurses are instructed not just on the CIWA-scoring strategy but on every aspect of the guidelines. As a result, nurses are now very invested in patient treatment.
"We have nurses coming to us talking about Valium doses and what is or isn’t enough for their patients," says Dr. Ibrahim. "That’s not just in the ED but in the step-downs and ICU."
He has no "hard data" yet on how well the guidelines are working or whether patients’ length of stay has dropped. (The guidelines were adopted in January 2010.) But anecdotally, Dr. Ibrahim says, "Morale about treating alcohol withdrawal among physicians and nurses is noticeably improved."
Nurses’ concerns about the extra work have been offset by the fact that patients improve more rapidly, he adds. But it’s the physicians who have benefited the most.
"The housestaff take the brunt of the volume of these patients," Dr. Ibrahim says. "They’ve noticed that patients are being handled more efficiently, and everybody is speaking the same lingo now when they hand off to each other."
Bonnie Darves is a freelance health care writer based in Seattle.