Symptom-triggered Vs Fixed
Dosing Schedules in the
Management of Alcohol
Withdrawal
Jay Murdoch
Alcohol Nurse Specialist
Background
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The number of dependant drinkers in
England stands at 1.6 million
The cost to the NHS is £2.7 Billion every
year and is set to rise to £3.7 Billion
Alcohol withdrawal often causes significant
management problems and complicates the
management of a wide variety of concurrent
conditions
The number of hospital admissions was 1.1
million in 2009/2010, a 100% increase since
2002/03.
Background Continued
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Although alcohol use and abuse are
common among inpatients, many patients
are inadequately assessed and treated for
alcohol withdrawal
Excessive drinking is currently the second
greatest risk to public health in developed
countries
Although most of that risk is avoidable the
risk is clearly apparent with the large
number of hospital admissions every year
The Project
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Is commissioned as part of
Manchester’s Alcohol Strategy
IBA work with harmful and hazardous
drinkers
Work with dependant drinkers
Reducing attendance rate of ‘frequent
fliers’
Alcohol Withdrawal Policy
Part 1 Aims
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Pre intervention audit
Identify current practice
Identify any short falls
Compare current practice to national
guidance
Identify a need for change in practice
Part 2 Aims
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Intervention stage
Implementation of an Integrated Care
Pathway (ICP)
Incorporating Assessment tool (CIWA score)
Management pathways
Standardise management of alcohol
withdrawal
Implementation of a symptom-triggered
approach to care
Part 3 Aims
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Post intervention audit- Complete
audit cycle
Has the intervention been successful?
Has practice improved?
Has patient care improved?
Has staff satisfaction improved?
Compare findings from both audits
Audit Tool
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Was the alcohol ICP used in the management of this patient?
Important to identify if the Trust guidelines are being met
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Number of days to complete detox?
Important to compare pre ICP and post ICP to note any improvement
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How much Chlordiazepoxide was administered?
Important to compare pre ICP and post ICP to note any improvement
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If ICP not commenced. Was PRN medication utilised?
This will identify if predetermined dosing regimes are used are staff trying to alleviate further
symptoms with as required medication
If PRN medication was used was it identified in the notes why?
This will highlight the need for CIWA scoring system that is part of ICP to improve assessment and
documentation
What drug is used in the detox process?
Will see if we are using the best available pharmacology to manage this group
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Is there consistency with prescribing?
This will identify any problems with medical prescribing. Are the medicines prescribed in proper place?
Are all areas of Kardex complete?
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Did anyone develop delirium or seizure activity following commencement on a detox?
This will help identify differences between symptom-triggered management and predetermined dosing.
Sample Groups
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Both groups contained fifty patients
Convenience sample
All patients completed a detox in
hospital
All patients were alcohol dependent
within DSMV-IV and ICD 10
classifications
Discussion
Pre ICP implementation
Practice
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No consistency with prescribing
No official guidelines
Prophylactic dosing regimes
Medication not individually tailored to
patient
Non-licensed medication being used
No assessment scoring to measure
withdrawal severity
Clinical Incidents
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As a background Clinical incidents
involving alcohol were investigated
Coroners court
Identified a need for change
Multiple incidents involving alcohol
No of days to complete a
detox
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Pre change average
number of days to
complete audit was
6.36 days
Post change
average number of
days to complete
audit was 2.48 days
How much Chlordiazepoxide
was administered?
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Pre implemenation-Average
number of milligrams to complete
an inpatient detox was 563.3 mg.
40% were given PRN medication
but in only 10% of these (2 cases)
was the reason for this
documented
Six of the prescriptions did not use
Chlordiazepoxide but used other
medication.
Post implementation- Average
number of milligrams of
Chlordiazepoxide to complete an
inpatient detox was 167.2 mg.
Chlordiazepoxide was the only
drug used
5 patients required no
Chlordiazepoxide
Consistency With
Prescribing
Pre Intervention
 No uniformity
 Differing regimes used
 Multiple prescribing
errors noted
 Administration errors
noted
Post Intervention
 All patients prescribed
the same medication
 All prescribed
appropriately
 All used symptomtriggered approach to
care
 Some administration
errors still
Development of further
withdrawal phenomena
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14 patients in the pre-intervention
group developed severe signs of
withdrawal following commencement
on a detox
Compared to 3 patients in the postintervention group
Staff Satisfaction
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A questionnaire was utilised using open and
closed questions
Was sent to 200 staff
138 were returned
Staff satisfaction was noted to improve
Staff had noted improvement in patient care
Documentation
Time management
Confidence
Documentation
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There are clear improvements in
documentation
This was needed as highlighted from
Coroners Court and other clinical incidents
All clinicians now documenting withdrawal
symptoms in same document
User friendly document allowing clinical staff
to score the symptoms therefore all
clinicians involved with patient can identify
what signs and symptoms the patient has
been portraying
Much easier to rule out Wernicke’s
encephalopathy or Anxiety related disorders
Costing
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The average cost of an inpatient stay is £300 per
night
The average cost to complete an inpatient detox
before symptom-triggered approach to care was
£1,908.
Compares to £744 for post intervention group.
Further costing reductions could be noteed in
pharmacy costs.
The printing costs for 3000 booklets/ICP’s is
£1191.72
Costing
Cost of detox for 50 patients
100000
90000
80000
70000
60000
Cost in pounds 50000
40000
30000
20000
10000
0
Cost of detox for 50 patients
Pre ICP
Post ICP
Pre-and-post ICP
Mann-Whitney Test
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Mann-Whitney parametric test used
P-value is 0.0001
Conclusions
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A symptom-triggered approach is
appropriate in the management of alcohol
withdrawal
Improves care
Improves treatment duration
Decrease in medication required
Harmonised clinical management
Improved documentation
Staff satisfaction noted
Significant Costing differences
References
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Alcohol Concern (2010) Investing in Alcohol Treatments: Reducing Costs and Saving.
Alcohol Concern. London.
Alcohol Concern (2011) Making Alcohol a Health Priority- Opportunities to Reduce alcohol
Harms and Rising Costs. Alcohol Concern. London.
Foy A., Kay J., and Taylor A. (2002) The course of alcohol withdrawal in a general
hospital. QJM Vol 90 pp. 253-261.
Kaner E. (2010) Brief interventions against excessive alcohol consumption. In: Oxford
Textbook of Medicine. Oxford University Press, Oxford, pp. 1334-1336
NICE (2010) Alcohol Use Disorders: Diagnosis and clinical management of alcohol related
physical complications. London. National Institute for Health and Clinical Excellence.
NICE (2010b) Alcohol Use Disorders: Sample Chlordiazepoxide dosing regimens for use
in managing alcohol withdrawal. London. National Institute for Health and Clinical
Excellence
Repper-Delisi J., Stern T.A., Mitchell M., Lussier-cushing M, Lakatose B.,Frichione G. et al.
(2008) Successful Implementation of an Alcohol- Withdrawal Pathway in a General
Hospital. Psychosomatics Vol 49(4) pp. 292-299.
Williams S., Brown A,. Patton R., Crawford M. and Touquet R. (2004) The half-life of the
‘teachable moment’ for alcohol misusing patients in the Emergency Department. Drug
and Alcohol Dependence Vol 77 pp. 205-208.