Hospitalized patients and alcohol: who is being missed?

Impact of an alcohol withdrawal screening and treatment protocol for hospitalized patients

INTRODUCTION

Alcohol Withdrawal Syndrome (AWS) is a potentially life-threatening complication of alcohol use disorder (AUD) that can be challenging to recognize in hospitalized patients. Our institution implemented universal AUD screening for all patients admitted to a non-critical care venue using the Prediction of Alcohol Withdrawal Severity Scale (PAWSS). At risk patients were then further assessed, utilizing the Glasgow Modified Alcohol Withdrawal Scale (GMAWS), and medicated according to a predetermined protocol. This study sought to determine whether this protocol decreased hospital length of stay, lowered the total benzodiazepine dose administered, and decreased adverse events attributable to AWS.

METHODS

This retrospective cohort study was conducted over a 6-year period from 2014 to 2020. The study included patients with an ICD-10 code diagnosis of AWS and subsequently divided them into two groups: pre- and post-protocol introduction. Outcome measures were compared pre- versus post-protocol introduction.

RESULTS

There were 181 patient encounters pre- and 265 patient encounters post-protocol. There was no statistically significant difference in median length of stay between the two groups (2.956 days pre and 3.250 days post-protocol, p = 0.058). Post-protocol, there was a statistically significant reduction in median total benzodiazepine dose (13.5 mg and 9 mg lorazepam equivalents pre- and post-protocol, p < 0.001) and in occurrence of delirium tremens (7.7 % pre and 2.3 % post-protocol, p = 0.006).

CONCLUSION

Protocol implementation did not reduce length of stay in patients with AUD but was associated with a significant reduction in total benzodiazepine dose and, when adjusted, a non-statistically significant decrease in progression to delirium tremens in hospitalized patients, after applying Bonferroni adjustment.

Alcoholism and American healthcare: The case for a patient safety approach

Alcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioral health condition. The aims of this paper are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population. The authors performed a narrative review of the literature on the current state of AUD treatment and patient safety, finding extensive evidence that patients with AUD usually go undiagnosed, unreferred and untreated. When they do receive AUD treatment, little evidence was found to indicate that a patient safety approach is incorporated into their care. Behavioral medicine is virgin territory for the patient safety movement. Medical care and behavioral medicine in the United States currently constitute two separate and unequal systems generally lacking in pathways of communication or care coordination for AUD patients. Significant barriers include institutional culture, individual and systemic bias against those with AUD, and health care infrastructure, especially the separation of medical and behavioral treatment. It is the authors’ conclusion that care of patients with AUD is unsafe. We advocate for the patient safety approach common in American hospitals to be extended to AUD treatment. Experienced patient safety leaders are in the strongest position to initiate collaboration between the mainstream medical and substance abuse treatment communities to reduce harm for this patient population.

Phenobarbital Monotherapy for the Management of Alcohol Withdrawal Syndrome in Surgical-Trauma Patients

BACKGROUND

Benzodiazepine is first-line therapy for alcohol withdrawal syndrome (AWS), and phenobarbital is an alternative therapy. However, its use has not been well validated in the surgical-trauma patient population.

OBJECTIVE

To describe the use of fixed-dose phenobarbital monotherapy for the management of patients at risk for AWS in the surgical-trauma intensive care unit.

METHODS

Surgical-trauma critically ill patients who received phenobarbital monotherapy, loading dose followed by a taper regimen, for the management of AWS were included in this evaluation. The effectiveness of phenobarbital monotherapy to treat AWS and prevent development of AWS-related complications were evaluated. Safety end points assessed included significant hypotension, bradycardia, respiratory depression, and need for invasive mechanical ventilation.

RESULTS

A total of 31 patients received phenobarbital monotherapy; the majority of patients were at moderate risk for developing AWS (n = 20; 65%) versus high risk (n = 11; 35%). None of the patients developed AWS-related complications; all patients were successfully managed for their AWS. Nine patients (29%) received nonbenzodiazepine adjunct therapy for agitation post-phenobarbital initiation. Three patients (10%) experienced hypotension, and 3 (10%) were intubated. None of the patients had clinically significant bradycardia or respiratory depression.

CONCLUSION AND RELEVANCE

Fixed-dose phenobarbital monotherapy appears to be well tolerated and effective in the management of AWS. Further evaluation is needed to determine the extent of benefit with the use of phenobarbital monotherapy for management of AWS.

Predischarge Injectable Versus Oral Naltrexone to Improve Postdischarge Treatment Engagement Among Hospitalized Veterans with Alcohol Use Disorder: A Randomized Pilot Proof-of-Concept Study

BACKGROUND

Injectable naltrexone for alcohol use disorders (AUDs) has been efficacious in several studies. It has not been (i) compared head-to-head with oral naltrexone or (ii) examined in the hospital setting as an intervention that might facilitate treatment attendance after hospital discharge.

METHODS

Fifty-four hospitalized veterans identified as having DSM-IV-TR alcohol dependence were randomized to receive (i) a 50 mg oral naltrexone plus a 30-day prescription or (ii) a 380 mg intramuscular naltrexone injection prior to discharge. Of 113 veteran inpatients deemed eligible based on screening criteria, 54 met final eligibility criteria and were enrolled and randomized. Baseline data included demographics, alcohol consumption, and comorbidity. Measures of treatment initiation and engagement and alcohol consumption were reassessed at 14- and 45-day follow-ups.

RESULTS

Thirty-five participants (64.8%) completed the entire study protocol (received a study medication and completed 14- and 45-day follow-ups). Among those who received a study medication (n = 45), 77.8% completed all follow-up interviews. This pilot study was not designed to have sufficient statistical power for hypothesis testing, and thus, as expected, there were no significant differences between groups in medication adherence (self-report of >80% of daily doses taken in oral group; receipt of second injection in the injection group), treatment engagement (at least treatment 3 visits in the 30 days postdischarge, and 2 or more visits per month in each of the 3 months following discharge) or alcohol consumption at 14 or at 45 days (p > 0.05). The median number of drinks among the entire cohort in the 2 weeks prior to hospitalization (128 drinks) was significantly higher than at day 14 (0 drinks, p < 0.001) or day 45 (0 drinks, p < 0.001). Rates of medication adherence were 62% in the oral group and 61% in the injection group.

CONCLUSIONS

Results indicate feasibility for larger, more definitive study. Both groups had significant reductions in alcohol consumption over time and high-treatment engagement rates. Both oral and injectable formulations are feasible to initiate prior to discharge for hospital inpatients identified as having an AUD.

The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome

BACKGROUND

To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill.

OBJECTIVES

Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool.

METHODS

For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS. A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS.

RESULTS

The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4.

DISCUSSION

The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.

Alcohol intoxication/dependence, ethnicity and utilisation of health care resources in a level I trauma center

OBJECTIVE

To evaluate the potential influence of acute intoxication and dependence to alcohol on extrautilisation of health care resources by ethnic minority trauma patients in a level I trauma center.

METHODS

We analysed the data of 1493 patients enrolled in a study that evaluated the effectiveness of brief alcohol intervention among ethnic minority trauma patients. The database included detailed demographic, injury-related and drinking-related characteristics (including acute intoxication and alcohol dependency status). Patients were categorised into the following groups: non-intoxicate/nondependent(NI/ND), non-intoxicated/dependent (NI/D), intoxicated/non-dependent (I/ND) and intoxicated/dependent (I/D). We compared utilisation of several diagnostic and therapeutic procedures among these four categories. We placed special emphasis on ethnicity as a potential effect modifier.

RESULTS

Relative to NI/ND trauma patients, I/ND patients (relative risk (RR): 1.8, 95% CI: 1.2–2.8) and I/D patients (RR: 2.4, 95% CI: 1.6–3.6) had significantly higher chance of being evaluated by abdominal ultrasound during the first 24 h of hospital arrival. Similar pattern was observed for head CT scan (with the corresponding RRs of 2.1 and 2.6, respectively). Chance of admission to the intensive care unit (ICU)was not associated with intoxication/dependence status. Length of hospital stay was negatively associated with drinking status with the shortest length of stay for I/D. Including ethnicity in the models,did not change the results and conclusions.

DISCUSSION

Acute intoxication and dependence to alcohol are both associated with more frequent utilisation of selected health care resources and the utilisation pattern was not associated with patient ethnicity. This emphasises on the importance of routine screening for drinking problems among all trauma patients, regardless of their blood alcohol level in the ED.

Can the blood alcohol concentration be a predictor for increased hospital complications in trauma patients involved in motor vehicle crashes?

The goal of this report is to assess the relationship of varying levels of blood alcohol concentration (BAC) and hospital complications in patients admitted after motor vehicle crashes. Data for the study was collected by a retrospective review of the University of Wisconsin Hospital trauma registry between 1999 and 2007 using the National Trauma Registry of the American College of Surgeons (NTRACS). Of 3729 patients, 2210 (59%) had a negative BAC, 338 (9%) <100 mg/dL, 538 (14%) 100-199 mg/dL, and 643 (17%) >200 mg/dL. Forty-six percent of patients had one or more hospital related complications. The odds ratio (OR) for the occurrence of alcohol withdrawal in the three alcohol groups compared to the no alcohol group was 12.02 (CI 7.0-20.7), 16.81 (CI 10.4-27.2), and 30.96 (CI 19.5-49.2) as BAC increased with a clear dose response effect. While there were no significant differences in the frequency of the total hospital events following trauma across the four groups, rates of infections, coagulopathies, central nervous system events and renal complications were lower in the high BAC group. Prospective studies are needed to more precisely estimate the frequency of hospital complications in patients with alcohol use disorders and in persons intoxicated at the time of the motor vehicle accident. The study supports the use of routine BAC to predict patients at high risk for alcohol withdrawal and the early initiation of alcohol detoxification.

Drink a little; take a few drugs: do nurses have knowledge to identify and manage in-patients at risk of drugs and alcohol?

INTRODUCTION AND AIMS

The widespread use of alcohol and other drugs poses particular problems during hospitalisation. Although nurses have been identified as an appropriate group to screen patients and provide acute and ongoing management to people with drug and alcohol-related problems, rates of screening are low. The aims of this study were to identify current practices for screening by nurses working in medical and surgical wards, determine their knowledge relating to problems associated with substance use and identify their self-reported skills in managing patients with drug- and alcohol-related problems.

DESIGN AND METHODS

A chart audit of medical records was completed and a survey was distributed to nurses working in the study wards.

RESULTS

Screening for alcohol and drug use was documented on only 22/79 medical records, and detailed information about quantity and duration of use was recorded in only nine. Overall, the nurses reported that they had little knowledge about substance use problems, and felt that they lacked skills to care adequately for these patients.

DISCUSSION AND CONCLUSIONS

The results of this study suggest a need for a comprehensive training and education to ensure that nurses are familiar with policies and protocols for management of patients and to assist nurses to provide evidence-based care and make appropriate referrals to specialist services.

Changes in general nurses' knowledge of alcohol and substance use and misuse after education

PURPOSE

This study aims to assess the impact of an education program on Australian general nurses' knowledge and competence in identifying and managing patients with alcohol and substance use and misuse, and compare findings with existing literature on mental health nurses.

DESIGN AND METHODS

Pre- and posttest design without a control group.

FINDINGS

The nurses' knowledge of safe drinking limits and alcohol withdrawal management improved following the education. Nevertheless, overall the nurses reported a lack of adequate knowledge and competence. Compared to mental health nurses, the nurses in this study had lower levels of knowledge and competence.

PRACTICE IMPLICATIONS

We suggest several opportunities for general nurses to strengthen their knowledge and skills and the need for a comprehensive and regular education program.

Suicide in the medical setting

BACKGROUND

Little is known about suicide in the hospital setting. Although suicide is a major public health concern, the literature on suicide in the medical setting is limited, and accurate data on hospital-based suicides are unavailable. Consequently, the prevalence, demographic characteristics, and risk factors for suicide in this population are unknown. The literature on completed suicides in medical or surgical wards of a general hospital was summarized to generate hypotheses for further investigation regarding in-hospital suicides.

METHODS

MEDLINE, PsycINFO, IndexCat, and Scopus were queried for English-language articles on inpatient suicides in a general hospital. These data were compared with reports of suicide by psychiatric inpatients and the annual suicide statistics from the U.S. general population.

RESULTS

Twelve articles detailing 335 suicides in the medical setting were included. Published data on hospital-based suicides are limited by selection bias, incomplete reporting, and a small number of completed suicides. Consequently, no significant setting-specific findings emerge from the existing literature. Reported cases suggest that inpatients who commit suicide in the medical setting may have a different demographic profile and employ different methods of suicide in comparison with individuals who commit suicide in psychiatric settings or the general population.

DISCUSSION

Given the absence of systematic data collection and the highly variable nature of reported suicides, it could not be determined if clinically relevant distinctions exist between suicides in different health care settings. Prospective and more detailed data collection are needed because a more complete characterization of suicide in medical inpatients may be useful in both prevention approaches and institutional policies with respect to hospital-based suicides.

Substance Use and Abuse in Trauma: Implications for Care

Trauma long has been associated with substance use and abuse. Caring for trauma patients who are intoxicated, withdrawing, or otherwise experiencing the negative outcomes of their substance use is difficult under the best of circumstances. The burden of this association can be described in many terms, from economic consequences, to health outcomes, to personal problems. Evidence indicates that untreated substance-associated trauma carries with it extended hospital stays, diminished quality of life, repeat emergency department use, and significant mortality and morbidity. No matter how one examines the burden of the association between substance use and trauma, one is left with the awareness that nurses can improve patient care through better screening, assessment, intervention, an evaluation. Because of the complex nature of the association between substance use and trauma, nursing care for these patients is difficult. Fig. 1 provides an overview of the factors to consider when planning care for these patients. Nurses need to focus on issues of temporality, directionality, and correlates of care as they plan for the needs of their patients. Only with careful considerations of these factors can the nurse clarify the confounding clinical presentation of the trauma overlaid on substance use. Evidence supports the need for all trauma patients to be screened for substance use and for those who have positive screens to receive early intervention. Although there is almost universal awarenes of the of the association between substance use and trauma and of the value of screening, screening rates for trauma patients are surprisingly low. Screening for substance use followed by BMI intervention is cost effective and should be implemented routinely. The high prevalence of substance-associated trauma, coupled with the heterogeneous nature of that association, warrants more study, particularly nursing research, to determine best-care practices. More research is needed to increase the understanding of patterns of use, etiologic models, and effective clinical care strategies. The need for this research is heightened by the awareness that substance-associated trauma is preventable, and the risk is modifiable. Nurses, everyday, are faced with the daunting challenge of meeting the health needs of trauma patients who have associated substance use. More research is needed to help nurses separate out the confounding health needs of these complex patients. That work has begun, and it assuredly will continue to support the need for high-quality nursing interventions to improve the health of trauma patients.