Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives

Impact of phenobarbital when used in combination with benzodiazepines for the treatment of alcohol withdrawal syndrome: A retrospective analysis

BACKGROUND AND OBJECTIVE

Alcohol withdrawal syndrome (AWS) is a serious complication of alcohol use disorder. Although benzodiazepines are the mainstay of treatment, some patients may be resistant to them, requiring rapidly escalating doses. Phenobarbital has emerged as an effective adjunct therapy in severe alcohol withdrawal, but studies have yielded inconsistent results and carry safety risks. The purpose of our study was to examine the effectiveness and the potential harm of phenobarbital in AWS.

METHODS

In this multi-center, retrospective cohort study, patients who were admitted for AWS and received phenobarbital with benzodiazepine were compared to patients who received benzodiazepine monotherapy. The primary outcome was time to AWS resolution. Other secondary and safety outcomes included length of stay (LOS), rate of mechanical ventilation, and incidence of aspiration pneumonia.

RESULTS

The phenobarbital group received significantly higher doses of benzodiazepines compared to the benzodiazepine monotherapy group (660 mg vs 340 mg, p < 0.0001). After adjustment, the use of phenobarbital was associated with significantly reduced time to AWS resolution (141.65 h vs 165.72 h, p < 0.0001). However, the use of phenobarbital was associated with the likelihood of mechanical ventilation (19.42 %vs. 0.96 %, p < 0.0001), aspiration pneumonia (22.33 % vs 5.77 %, p = 0.0006), and increased hospital LOS (8 days vs. 6 days, p = 0.0197). In the combination group, earlier phenobarbital initiation (within 24 h) was associated with significantly lower cumulative benzodiazepine dose (530 mg vs 887.50 mg, p = 0.002) and hospital LOS (6 days vs 10 days, p = 0.0017).

CONCLUSION AND RELEVANCE

In our study, patients who received phenobarbital in combination with benzodiazepines had a quicker resolution of AWS but also had a higher incidence of mechanical ventilation, prolonged hospital LOS, and an increased risk of aspiration pneumonia. For patients at high risk of severe alcohol withdrawal, earlier initiation of phenobarbital appeared to yield the most optimal benefit.

Alcohol-induced psychosis and delirium tremens: a comparison with alcohol dependence on demographic characteristics, mortality, and morbidity

OBJECTIVES

The study aim was to compare patients with alcohol-induced psychosis (AIP) and delirium tremens (DT) with patients with alcohol dependency (AD) only. Using data from Norwegian Patient Registry (NPR) we investigated demographic characteristics, mortality, and physical and mental health comorbidities, among individuals with AIP or DT compared with AD patients.

METHODS

Data from NPR was used to create a cohort of patients aged 20-79 diagnosed with either AIP, DT or AD, from 2009 to 2015. If patients received more than one of these diagnoses, AIP and DT were prioritized. For patients with both AIP and DT, the earliest diagnosis took priority, except when the diagnoses were assigned simultaneously, when DT was prioritized. Data on comorbidities were taken from NPR, while cause of death was obtained from the Norwegian Cause of Death Registry. Estimates were compared using chi-square test and the Kruskal-Wallis test with Bonferroni adjustments for multiple testing. Mortality was analysed using Cox regression models and by calculating standardized mortality ratios, adjusting for age and gender.

RESULTS

The cohort included 33 107 patients diagnosed with AD, 1 784 with DT, and 700 with AIP. AIP patients were the youngest. DT patients displayed significantly higher mortality rates, with an annual rate of 8.0%, and generally increased comorbidity rates. AIP patients showed significantly higher rates of schizophrenia spectrum disorders compared to both AD and DT patients, highlighting a potential link between AIP and psychotic disorders.

CONCLUSION

This study reveals that patients with DT experience higher morbidity and mortality rates compared to those with AIP and AD. AIP patients did not show increased all-cause or cause-specific mortality compared to AD patients across a variety of causes. Notably, AIP seemed to be more closely linked to comorbid schizophrenia spectrum disorders than AD and DT patients. The findings underscore the complexities of AIP in relation to schizophrenia and highlight significant differences in health outcomes among the three patient groups.

Global emergency medicine research priorities: a mapping review

Recognizing and prioritizing research areas in emergency care is crucial for generating evidence and advancing research programs, aiming to enhance health outcomes for both individuals and populations. The objective of this review is to document global clinical and nonclinical research priorities. The Emergency Medicine Education and Research by Global Experts network, consisting of 22 sites across six continents, conducted a mapping review of publications on emergency medicine research priorities (2000-2022) across seven databases. We included studies with replicable methodologies for determining research priorities, excluding those limited to individual diseases. Three reviewers independently screened, selected, and categorized results into clinical and nonclinical topics. Discrepancies were resolved by an independent investigator and consensus. Outcomes measures and analysis include descriptive analysis of research priorities grouped into clinical and nonclinical topics, characteristics of publications including countries represented in the author list, target audience (such as researchers or policy makers), participants (e.g. patients), and methods (e.g. Delphi) of priority setting. Among 968 screened papers, 57 publications from all WHO regions were included. Most (36, 63%) had authors from only a single country, primarily in North America and Europe. Patient representatives were included in only 10 (18%). Clinical research priorities clustered into resuscitation, cardiology, central nervous system, emergency medical services, infectious disease, mental health, respiratory disease, and trauma. Distribution was broad in North America and Europe but focused on infectious diseases and resuscitation in Africa and Asia. Eleven nonclinical topics included access to care, health policy, screening/triage, social determinants of health, staffing, technology/simulation, shared decision making, cross-sectoral collaboration, education, patient-centered care, and research networks. Nonclinical topics were broad in Europe and America, focused on access to care and health screening in Africa, and mostly absent in other WHO regions. Published research priorities in emergency medicine are heterogeneous and geographically limited, mostly containing groups of authors from the same country. The majority of publications in global research priority setting stem from Western countries, covering a broad spectrum of clinical and nonclinical topics. Research priorities from Africa and Asia tend to focus on specific issues more prevalent in those regions of the world.

Plasma neurofilament light chain levels are associated with delirium tremens in patients with alcohol use disorder

Delirium tremens (DT) is the most severe and life-threatening manifestation of alcohol withdrawal. Prompt identification and treatment are crucial in the clinical management of DT, but laboratory markers in this context are still lacking. Neurofilament light chain (NfL) has been proposed as a novel blood marker of neuroaxonal pathology. Therefore, we investigated the association between plasma NfL levels on admission and the occurrence of DT in patients with alcohol use disorder (AUD). NfL levels were measured on admission in 224 patients with AUD undergoing alcohol withdrawal treatment and in 116 healthy individuals. We monitored patients with AUD during the following 2 weeks of hospitalization and categorized them according to the prospective occurrence of DT (n = 25) or not (n = 199). Plasma NfL levels at admission were highest in patients who later developed DT, compared to AUD patients without DT, and healthy individuals (63.1 ± 47.2, 24.0 ± 22.4, 11.8 ± 6.1 pg/mL, respectively, p < 0.001). Receiver operating characteristic analysis revealed that a cut-off NfL level of 27.2 pg/mL could discriminate AUD patients who later developed DT (sensitivity: 80.0 %; specificity: 72.4 %; area under the curve: 0.84, p < 0.001), with an odds ratio of 9.43 (95 % CI 3.26-27.32; p < 0.001) for the risk of developing DT. Our findings suggest that NfL levels at admission may predict DT occurrence in patients with AUD and implicate neuroaxonal pathology in the pathophysiology of DT. Further research is needed to validate these findings and to explore the underlying neurobiological mechanisms.

Emergency care utilization in persons with substance related diagnoses

Background

Substance use is a significant contributor to emergency department (ED) visits. Little is known about ED utilization patterns of individuals with substance related diagnosis (SRD). We used electronic health records (EHR) from a large healthcare system in California to examine ED healthcare utilization and socio-demographic characteristics of individuals with SRDs.

Methods

We used EHR data on all adult patients in our health system from April 2012 through September 2019 to conduct adjusted logistic regression models to determine socio-demographic correlates of SRDs (e.g., use, misuse, dependence) and associations between having an SRD and receiving emergency care.

Results

Among the sample (n = 342,651), the majority were female (55.08 %), Non-Hispanic White (58.10 %), with mean age of 48.26 (SD = 18.10), and there were 18,015 (5.26 %) individuals with an SRD. Patients with an alcohol-related diagnosis had the highest odds of visiting the ED (aOR = 3.75), followed by those with opioid (aOR = 3.57) and stimulant-related diagnoses (aOR = 3.48). Individuals with an SRD were more likely to identify as male, Black/African American, Hispanic/Latinx, have no health insurance, and have a serious mental illness. In the adjusted model, those with an SRD were significantly more likely to have ever received emergency care (aOR 3.72 [95 % CI 3.62-3.84]) than those without an SRD.

Discussion

Our study found an association between having an SRD and utilizing emergency health services. Demographic characteristics suggest disparities exist for those with SRDs around gender, race/ethnicity, insurance status, and mental health. These data can help with screening and targeted responses to prevent or provide emergency care.

Clear Minds: Unravelling Delirium in Older Adults

With an explosive population growth of older adults, the incidence rates of neuropsychiatric syndromes, particularly delirium, are increasing in the community and hospital settings. Delirium is an acute disturbance in cognition and attention that may signify a serious medical, life-threatening condition and may mimic psychiatric-mental health issues. Although its prevalence rate is lower in the community, delirium affects up to 87% of hospitalized older adults and can cost up to $152 billion each year. Despite its common occurrence, delirium is often undetected in 50% to 60% across all care settings, delaying treatment and resulting in poor patient outcomes, such as increased mortality, prolonged hospital stays, cognitive and functional impairment, decreased quality of life, and institutionalization. The current article addresses strategies to recognize delirium and presents evidence-based approaches and future considerations for delirium management. [Journal of Psychosocial Nursing and Mental Health Services, 62(11), 11-18.].

Is Phenobarbital an Effective Treatment for Alcohol Withdrawal Syndrome?

BACKGROUND

Alcohol use disorder is associated with a variety of complications, including alcohol withdrawal syndrome (AWS), which may occur in those who decrease or stop alcohol consumption suddenly. AWS is associated with a range of signs and symptoms, which are most commonly treated with GABAergic medications.

CLINICAL QUESTION

Is phenobarbital an effective treatment for AWS?

EVIDENCE REVIEW

Studies retrieved included two prospective, randomized, double-blind studies and three systematic reviews. These studies provided estimates of the effectiveness and safety of phenobarbital for treatment of AWS.

CONCLUSIONS

Based on the available literature, phenobarbital is reasonable to consider for treatment of AWS. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for treatment of AWS.

Views and experiences of involuntary civil commitment of people who use drugs in Massachusetts (Section 35)

BACKGROUND

Involuntary civil commitment (ICC) is a court-mandated process to place people who use drugs (PWUD) into substance use treatment. Research on ICC effectiveness is mixed, but suggests that coercive drug treatment like ICC is harmful and can produce a number of adverse outcomes. We qualitatively examined the experiences and outcomes of ICC among PWUD in Massachusetts.

METHODS

Data for this analysis were collected between 2017 and 2023 as part of a mixed-methods study of Massachusetts residents who disclosed illicit drug use in the past 30-days. We examined the transcripts of 42 participants who completed in-depth interviews and self-reported ICC. Transcripts were coded and thematically analysed using inductive and deductive approaches to understand the diversity of ICC experiences.

RESULTS

Participants were predominantly male (57 %), white (71 %), age 31-40 (50 %), and stably housed (67 %). All participants experienced ICC at least once; half reported multiple ICCs. Participants highlighted perceptions of ICC for substance use treatment in Massachusetts. Themes surrounding ICC experience included: positive and negative treatment experience's, strategies for evading ICC, disrupting access to medications for opioid use disorder (MOUD), and contributing to continued substance use and risk following release.

CONCLUSIONS

PWUD experience farther-reaching health and social consequences beyond the immediate outcomes of an ICC. Findings suggest opportunities to amend ICC to facilitate more positive outcomes and experiences, such as providing sufficient access to MOUD and de-criminalizing the ICC processes. Policymakers, public health, and criminal justice professionals should consider possible unintended consequences of ICC on PWUD.

Prevalence and Predictors of Non-Benzodiazepine Use in Patients with Alcohol Withdrawal Syndrome in United States Emergency Departments - a cross-sectional study

Purpose: Benzodiazepines are the mainstay treatment in Alcohol Withdrawal Syndrome (AWS), though they have the potential for abuse and cognitive side effects. Non-benzodiazepines are of growing interest for treatment of AWS; however, the prevalence of non-benzodiazepine use remains unknown. The purpose of this study is to evaluate the prevalence and predictors of non-benzodiazepine use for AWS in the Emergency Department (ED). Methods: A cross-sectional, retrospective study utilizing data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) spanning the years 2014-2020 investigated patients presenting to the ED with AWS. The primary outcome of this study is the prevalence of patients with AWS who received non-benzodiazepine treatment during their ED visit. The secondary outcome was the identification of predictor variables for non-benzodiazepine use. A multivariate logistic regression with a backward elimination approach was employed to identify predictor variables. Results: A total of 2,300 unweighted ED visits included over the study years. When weighted, this represented over 15.2 million ED visits. Across the study period, 3.1% (95% CI, 1.6-6.1%) of patients received non-benzodiazepines. Positive predictors of non-benzodiazepine use included the year 2020 compared to 2014 (OR 6.32, 95% CI, 1.39-28.73) and comorbid depression (OR 4.13, 95% CI, 1.38-12.36). Negative predictors of non-benzodiazepine use included ages 18-40 compared to ages 41-64 (OR 0.34, 95% CI, 0.13-0.91), nursing home residence compared to private residence (OR 0.02, 95% CI, 0.001-0.80), and the South compared to the Midwest region of the United States (OR 0.19, 95% CI, 0.07- 0.51). Conclusion: This study found that non-benzodiazepine use, despite being less common, is becoming more prevalent. Further research is needed to determine the optimal dosing and duration of non-benzodiazepines for AWS. Understanding the factors influencing the prescription patterns of non-benzodiazepines can contribute to informed decision-making and improve the management of AWS.

Alterations in Neurotrophins in Alcohol-Addicted Patients during Alcohol Withdrawal

BACKGROUND

Alcohol use disorder (AUD) is related to mental and somatic disorders that result in alcohol withdrawal syndrome (AWS), with 30% of AWS cases leading to life-threatening delirium tremens (DTs). Currently, studies do not support using any one biomarker in DTs. Neurotrophins affect neuromodulation, playing a role in the pathogenesis of AUD, AWS, and DTs.

METHODS

This review aims to summarize experimental and clinical data related to neurotrophins and S100B in neuroplasticity, as well as neurodegeneration in the context of AUD, AWS, and DTs. This work used publications that were selected based on the protocol consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

RESULTS

The BDNF level could be a good candidate biomarker for relapse susceptibility, as it is significantly reduced during consumption and gradually increases during abstinence. GDNF influences AUD through its integral role in the function of dopaminergic neurons and ablates the return to alcohol-drinking behavior. NGF protects neurons from ethanol-induced cytotoxic damage and affects recovery from cognitive deficits after brain damage. The NT-3 level is decreased after alcohol exposure and is involved in compensatory mechanisms for cognitive decline in AUD. NT-4 affects oxidative stress, which is associated with chronic alcohol consumption. S100B is used as a biomarker of brain damage, with elevated levels in serum in AUD, and can protect 5-HT neurons from the damage caused by alcohol.

CONCLUSIONS

BDNF, GDNF, NT-3, NT-4, NGF, and S100B may be valuable markers for withdrawal syndrome. In particular, the most relevant is their association with the development of delirium complications. However, there are few data concerning some neurotrophins in AWS and DTs, suggesting the need for further research.

Replacing the Clinical Institute Withdrawal Assessment-Alcohol revised with the modified Richmond Agitation and Sedation Scale for alcohol withdrawal to support management of alcohol withdrawal symptoms: potential impact on length of stay and complications

PURPOSE

We evaluated impact on length of stay and possible complications of replacing the Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar) scale with a slightly modified Richmond Agitation and Sedation Scale (mRASS-AW) to support managing patients admitted with alcohol withdrawal symptoms in a community hospital. Since mRASS-AW is viewed as easier and quicker to use than CIWA-Ar, provided use of mRASS-AW does not worsen outcomes, it could be a safe alternative in a busy ED environment and offer an opportunity to release nursing time to care.

METHODS

Retrospective time-series analysis of mean quarterly length of stay. All analyses exclusively used our hospital's administrative discharge diagnoses database. During April 1st 2012 to December 14th 2014, the CIWA-Ar was used in the ED and in-patient units to guide benzodiazepine dosing decisions for alcohol withdrawal symptoms. After this point, CIWA-Ar was replaced with mRASS-AW. Data was evaluated until December 31st 2020.

PRIMARY OUTCOME

mean quarterly length of stay.

SECONDARY OUTCOMES

delirium, intensive care unit (ICU) admission, other post-admission complications, mortality.

RESULTS

N = 1073 patients. No association between length of stay and scale switch (slope change 0.3 (95% CI - 0.03 to 0.6), intercept change, 0.06 (- 0.03 to 0.2). CIWA-Ar (n = 317) mean quarterly length of stay, 5.7 days (95% 4.2-7.1), mRASS-AW (n = 756) 5.0 days (95% CI 4.3-5.6). Incidence of delirium, ICU admission or mortality was not different. However, incidence of other post-admission complications was higher with CIWA-Ar (6.6%) than mRASS-AW (3.4%) (p = 0.020).

CONCLUSIONS

This was the first study to compare patient outcomes associated with using mRASS-AW for alcohol withdrawal symptoms outside the ICU. Replacing CIWA-Ar with mRASS-AW did not worsen length of stay or complications. These findings provide some evidence that mRASS-AW could be considered an alternative to CIWA-Ar and potentially may provide an opportunity to release nursing time to care.

Phenobarbital treatment of alcohol withdrawal in the emergency department: A systematic review and meta-analysis

OBJECTIVE

Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative therapy is mixed. We conducted a systematic review and meta-analysis comparing safety and efficacy of PB to benzodiazepines (BZDs) for treatment of AWS in the ED.

METHODS

We searched articles and references published in English in PubMed, Web of Science, and Embase from inception through May 2022. We included randomized trials and cohort studies comparing treatment with PB to BZD controls and excluded studies focused on non-AWS conditions. Review was conducted by two blinded investigators and a third author; eight of 59 (13.6%) abstracts met inclusion criteria for review and meta-analysis using a random-effects model. Treatment superiority was evaluated through utilization, pharmacologic, and clinical outcomes. Primary outcomes for meta-analysis were the proportion of patients (1) admitted to the intensive care unit (ICU), (2) admitted to the hospital, (3) readmitted to the ED after discharge, and (4) who experienced adverse events.

RESULTS

Eight studies (two randomized controlled trials, six retrospective cohorts) comprised data from 1507 patients in 2012 treatment encounters for AWS. All studies were included in meta-analysis for adverse events, seven for hospital admission, five for ICU admission, and three for readmission to the ED after discharge. Overall methodological quality was low-moderate, risk of bias moderate-high, and statistical heterogeneity moderate. Pooled relative risk of ICU admission for those treated with PB versus BZD was 0.92 (95% confidence interval [CI] 0.54-1.55). Risk for admission to the hospital was 0.98 (95% CI 0.89-1.07) and for any adverse event was 1.1 (95% CI 0.78-1.57); heterogeneity prevented meta-analysis for ED readmission.

CONCLUSIONS

The current literature base does not show that treatment with PB significantly reduces ICU admissions, hospital admissions, ED readmissions, or adverse events in ED patients with AWS compared with BZDs alone.

SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence

OBJECTIVES

Alcohol withdrawal syndrome (AWS) is a commonly presenting condition in the emergency department (ED) and can have severe complications, including mortality. Benzodiazepines are first-line medications for treating AWS but may be unavailable or insufficient. This systematic review evaluates the direct evidence assessing the utility of phenobarbital for treating AWS in the ED.

METHODS

A systematic search was conducted and designed according to the patient-intervention-comparator-outcome (PICO) question: (P) adults (≥18 years old) presenting to the ED with alcohol withdrawal; (I) phenobarbital (including adjunctive); (C) benzodiazepines or no intervention; and (O) AWS complications, admission to a monitored setting, control of symptoms, adverse effects, and adjunctive medications. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies.

RESULTS

From 70 potentially relevant articles, seven studies met inclusion criteria: three retrospective cohort studies, two retrospective chart reviews, and two randomized controlled trials (RCTs), one examining phenobarbital monotherapy and one examining adjunctive phenobarbital. Across the retrospective cohort studies, treatment of AWS with phenobarbital resulted in lower odds of a subsequent ED visit. The retrospective chart reviews indicated that phenobarbital was associated with higher discharge rate compared to benzodiazepine-only treatments. For the two RCTs, phenobarbital did not differ significantly from benzodiazepine for most outcomes, although concomitant treatment with phenobarbital was associated with lower benzodiazepine use and intensive care unit admission. The heterogeneous designs and small number of studies prevented quantitative synthesis.

CONCLUSIONS

Relatively few studies provide direct evidence on the utility of phenobarbital for AWS in the ED, but the evidence that exists generally suggests that it is a reasonable and appropriate approach. Additional RCTs and other methodologically rigorous investigations are needed for more definitive direct evidence.

The possible clinical utility of the alcohol biomarker phosphatidylethanol for managing suspected alcohol withdrawal in hospitalized patients: A case report

BACKGROUND AND OBJECTIVES

The decision to initiate pharmacotherapy for alcohol withdrawal is typically based on examining self-reported use of alcohol and symptoms of withdrawal. Phosphatidylethanol (PEth) is a biomarker that could aim in clinical decision-making in withdrawal management.

METHODS

This report describes three cases highlighting the potential clinical utility of PEth in caring for individuals at risk for alcohol withdrawal.

RESULTS

Two of the cases received phenobarbital when their PEth showed that the risk of withdrawal was low and one case where PEth could have shown this was needed. The results were only available in a delayed fashion, however, could have been useful in informing clinical care.

DISCUSSION AND CONCLUSION

PEth can be a useful tool if available without delay. PEth can be used to quickly rule out alcohol withdrawal and avoid misdiagnoses and prolonged hospital stays.

SCIENTIFIC SIGNIFICANCE

This is a clinical case study available looking at PEth and withdrawal in hospitalized patients. It proposes that PEth can be used as a way to quickly rule out alcohol withdrawal to avoid misdiagnoses and the possibility of a prolonged hospital stay.

Delirium Tremens: A Review of Clinical Studies

Delirium tremens (DT) is a severe condition resulting from alcohol withdrawal. This review highlights the challenges in diagnosing and managing DT and emphasizes the importance of early recognition and intervention to prevent complications and ensure optimal patient outcomes. The discussion of the pathophysiology of DT, focusing on the neurochemical imbalances involving the neurotransmitters gamma-aminobutyric acid and glutamate, explains how chronic alcohol dependence leads to these imbalances and contributes to the hyperexcitability seen in DT. The management of DT involves ensuring patient safety and alleviating symptoms, primarily through pharmacological approaches, such as benzodiazepines. Closely monitoring vital signs and electrolyte imbalances is necessary due to autonomic dysregulation associated with DT. The mention of the potential complexity of DT when coexisting with other conditions emphasizes the need for additional research to advance comprehension, identify predictive factors, and enhance its management.

C-L Case Conference: The Case of a 34-Year-Old Male Veteran with Suicidal Ideation in the Context of Alcohol Intoxication

We describe the case of a 34-year-old male veteran who presents to the emergency department with suicidal ideation while intoxicated on alcohol. From his progression from intoxication through sobriety, this case details changes in his suicide risk during the sobering process. Consultation-liaison psychiatrists present guidance for this clinical scenario based on their experiences and a review of the available literature. The following important concepts for managing suicide risk among patients with alcohol intoxication are considered: evaluating for medical risk, timing the suicide risk assessment, anticipating withdrawal, diagnosing other disorders, and achieving a safe disposition.

Flow through the Emergency Department for Patients Presenting with Substance Use Disorder in Alberta, Canada

INTRODUCTION

Since 2016 the province of Alberta, Canada, has seen a significant increase in substance use disorder (SUD) presentations to the emergency department (ED) with a large surge during the COVID-19 pandemic. In this retrospective study we deconstruct the total length of stay (LOS) in the ED into stages for patients presenting with SUD and estimate the effects of covariates on the time to transition between stages.

METHODS

Using the Canadian Coding Standards for International Classification of Diseases, 10^th Modification, codes F10.0-F19.9 and T36.0-T50.9, we extracted data from the National Ambulatory Care Reporting System between April 1, 2019-March 31, 2020 on all ED presentations for SUD by Alberta residents. We used a multistate model to deconstruct the EDLOS into eight mutually exclusive states and determine which factors affected the time spent in each state.

RESULTS

We analyzed 66,880 presentations (37,530 patients). The mean age was 37.2 years, and 61% were male. The median total LOS in the ED was 6 hours 13 minutes. Patients presenting with methamphetamines (METH) intoxication and patients from low-income neighborhoods had significantly increased transition times between all states. Opposite this, opiate use was associated with faster transition times between almost all states. Metro EDs experienced slower transitions when attempting to discharge or admit patients when compared to urban or rural EDs. Emergency department crowding also had a dramatic effect on physician initial assessment times, while discharge and admission times in patients presenting with SUD were also significantly affected.

CONCLUSION

Patients with SUD experience a variety of delays during their ED stay. Those with METH intoxication and those from the lowest income neighborhoods were most likely to experience slower transitions from state to state in the ED and may benefit from a focused approach to improve ED flow.

Acceptability Among Frontline Staff Toward Distributing an Anonymous Alcohol Survey in Emergency Departments: A Mixed Methods Study

ABSTRACT

Emergency departments (EDs) serve as the front line when patients encounter the hospital system. Limited data are available of patients' alcohol habits collected during Danish ED visits, and no studies have, to our knowledge, examined frontline staffs' (registered nurses and medical secretaries) acceptability to deliver anonymous alcohol surveys to patients. We aimed at examining the proportion of survey respondents and the prevalence of patients' alcohol habits and also exploring frontline staff acceptability of the distribution of an anonymous survey regarding patients' alcohol habits in EDs. Intendedly, all eligible patients ≥18 years old entering two EDs in March 2019 should receive a survey based on the Alcohol Use Disorder Identification Test. The study was an explanatory, sequential, mixed methods design, and results were analyzed with descriptive statistics and a deductive content analysis based on the theoretical framework of acceptability. In total, 15% (n = 1,305) of the total 8,679 patients in the EDs returned the survey. Qualitative analysis of interviews (n = 31) with staff showed that they had been reluctant to distribute the survey primarily because of ethical concerns of anonymity, freedom of choice, and being nonjudgmental toward patients. Hence, patients with no obvious alcohol problems were more likely to receive the survey. Still, we found that 23% of the respondents had an Alcohol Use Disorder Identification Test score ≥ 8. Results indicate that frontline staffs' recognition of patients' alcohol use is inadequate, and findings show a low degree of acceptability among staff to deliver an anonymous survey, which is in line with earlier described barriers toward screening activities in EDs.

Alcohol Withdrawal with Delirium Tremens

Audience

Emergency medicine (EM) residents (1st year and 2nd year levels), 4th year medical students and advanced practice providers.

Introduction

Alcohol use has played a major role in causing significant morbidity and mortality for patients. In 2016, it was the 7th leading risk factor for deaths and disability-adjusted life years globally.1 Among heavy alcohol users admitted for hospital management, the incidence of alcohol withdrawal syndrome is estimated to be 1.9 to 6.7%.1 Alcohol withdrawal (AW) in the ED has been associated with increased use of critical care resources, and frequent ED visits for alcohol-related presentations have been associated with mortality rates that are about 1-4% when withdrawal progresses to delirium tremens (DTs).1 Patients with alcohol withdrawal can present in many different ways to the ED including anxiety, tachycardia, delirium tremens (DTs), seizures and severe autonomic dysfunction leading to severe sickness and death.2 Therefore, it is extremely important for an EM physician to recognize the signs of AW in patients and to manage the critically ill patients. In addition, Clinical Institute Withdrawal Assessment (CIWA) of alcohol was developed to assess severity of alcohol withdrawal in 1989.3 EM physicians should utilize CIWA to help determine the severity of AW.

Educational Objectives

By the end of the session, learner will be able to 1) discuss the causes of altered mental status, 2) utilize CIWA scoring system to quantify AW severity, 3) formulate appropriate treatment plan for AW by treating with benzodiazepine and escalating treatment appropriately, 4) treat electrolyte abnormalities by giving appropriate medications for hypokalemia and hypomagnesemia, and 5) discuss clinical progression and timing to AW.

Educational Methods

This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. The session was run during first year EM resident intern orientation, and it was run during two consecutive years. There was a total of 32 EM residents who participated. There was a total of 16 residents who actively managed the patient while the other 16 were observers. Each session had four learners and was run twice in two separate rooms. There was one simulation instructor running the session and one simulation technician who acted as a nurse.

Research Methods

After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the participants. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right the amount of complexity (based on their Gestalt), (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. The responses were collected using a Likert scale of 1 to 5 with 1 being "Strongly disagree" and 5 being "Strongly agree."

Results

There was a total of 15 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning, in improving medical knowledge and in patient care. All of them found the post-session debrief to be very helpful. Two of them felt neutral about the case being realistic. The median response for questions 1, 3 and 5 is 5. The median response for questions 2 and 4 was 4. The range of responses for questions 1, 2, 3 and 5 was 4-5 while the range for question 4 was 3-5.

Discussion

This high-fidelity simulation was a cost-effective and realistic way of educating learners on how to manage AW with DTs. Learners are forced to start with a broad differential for the patient who presents with AMS. As they recognize the cause of mental status, the patient quickly decompensates into developing severe agitation and autonomic dysfunction requiring learners to manage the patient and establish an airway. Learners found the case to be beneficial in learning the management of AW.

Topics

Alcohol withdrawal, delirium tremens, agitation, altered mental status.

Protective effect of methanolic extract of Areca catechu nut on ethanol withdrawal symptoms in mice

Background

The purpose of the current study was to examine the potential impact of a methanolic extract of Areca catechu nut (MAN) on handling-induced convulsions (HIC), anxiety and anhedonia behaviour of alcohol-withdrawn mice. 30 female Swiss albino mice were divided into 5 groups, each with 6 animals. Group 1 (saline withdrawal) received saline during the 3-day alcohol/saline induction phase, while the other 4 groups (alcohol withdrawal) received 20% v/v ethanol (1.25 ml/100 g body weight, i.p.; 20% v/v ethanol was made from absolute ethanol with 79.9 ml saline + 0.1 ml fomepizole, an alcohol dehydrogenase inhibitor). Day four (test day) involved studying handling-induced convulsions; open field test (OFT), elevated plus maze test (EPM), marble burying test (MBT) for anxiety; 24-h sucrose preference test (SPT) for anhedonia in mice. On the test day, Group I and II (saline withdrawal and alcohol withdrawal) received oral treatments with 1% w/v sodium carboxyl methylcellulose 1 h prior to the behavioural testing. Group III received an injection of diazepam (1 mg/kg, i.p., 30 min prior) and Group IV and V were treated with two different doses of MAN (50 and 100 mg/kg, p.o.) 1 h prior to the behavioural test.

Results

At doses of 50 and 100 mg/kg, p.o., the Areca catechu nut methanolic extract significantly reduced handling convulsions and anxiety, and had an anti-anhedonic effect using various evaluation criteria, such as convulsion score (HIC), no. of central and peripheral line crossings (OFT), % entries and time spent in open arms (EPM), no. of marbles buried (MBT), and sucrose intake ratio (SPT) in alcohol-withdrawn mice.

Conclusion

In mice undergoing alcohol withdrawal, Areca catechu nut extract (MAN) greatly lessens handling-induced convulsions, anxiety and depression symptoms.

Graphical Abstract

Delirium in a surgical context from a nursing perspective: A hybrid concept analysis

Background

The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed.

Objective

The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective.

Design

The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases.

Settings

Surgical wards, surgical intensive care units, and post-anaesthesia care units.

Data sources

A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase.

Participants

Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase.

Methods

In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported.

Results

The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care.

Conclusions

In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.

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.

Diagnostic Performance of AST Scale in Mexican Male Population for Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome (AWS) represents an adverse consequence of chronic alcohol use that may lead to serious complications. Therefore, AWS requires timely attention based on its early recognition, where easy-to-apply diagnostic tools are desirable. Our aim was to characterize the performance of a short-scale AST (Anxiety, Sweats, Tremors) in patients from public general hospitals. We conducted a cross-sectional study of patients attended at the Emergency Department diagnosed with AWS. Three scales were applied: CIWA-Ar (Clinical Institute Retirement Assessment Scale-Revised), GMAWS (Glasgow Modified Alcohol Withdrawal Syndrome) and AST. Cronbach’s alpha and Cohen’s kappa tests were used for reliability and concordance. Factorial analysis and diagnostic performance including ROC curve were carried out. Sixty-eight males with a mean age of 41.2 years old, with high school education and robust alcohol consumption, were included. Mean scores for CIWA-Ar, GMWAS and AST were 17.4 ± 11.2, 3.9 ± 2.3 and 3.8 ± 2.6, respectively, without significant differences. The AST scale showed an acceptable reliability and concordance (0.852 and 0.439; p < 0.0001) compared with CIWA-Ar and GMAWS. AST component analysis evidenced tremor (77.5% variance), sweat (12.1% variance) and anxiety (10.4% variance). Diagnostic performance of the AST scale was similar to the GMAWS scale, evidencing a sensitivity of 84%, specificity of 83.3% and Area Under the Curve (AUC) of 0.837 to discriminate severe AWS, according to CIWA-Ar. The performance of the AST scale to evaluate AWS is comparable with the commonly used CIWA-Ar and GMAWS scales. AST further represents an easy-to-apply instrument.

Provider perspectives on emergency department initiation of medication assisted treatment for alcohol use disorder

Background

Alcohol use disorder (AUD) is ubiquitous and its sequelae contribute to high levels of healthcare utilization, yet AUD remains undertreated. The ED encounter represents a missed opportunity to initiate medication assisted treatment (MAT) for patients with AUD. The aims of this study are to identify barriers and facilitators to the treatment of AUD in the ED, and to design interventions to address identified barriers.

Methods

Using an implementation science approach based on the Behavior Change Wheel framework, we conducted qualitative interviews with staff to interrogate their perspectives on ED initiation of AUD treatment. Subjects included physicians, nurses, nurse practitioners, clinical social workers, and pharmacists. Interviews were thematically coded using both inductive and deductive approaches and constant comparative analysis. Themes were further categorized as relating to providers’ capabilities, opportunities, or motivations. Barriers were then mapped to corresponding intervention functions.

Results

Facilitators at our institution included time allotted for continuing education, the availability of clinical social workers, and favorable opinions of MAT based on previous experiences implementing buprenorphine for opioid use disorder. Capability barriers included limited familiarity with naltrexone and difficulty determining which patients are candidates for therapy. Opportunity barriers included the limited supply of naltrexone and a lack of clarity as to who should introduce naltrexone and assess readiness for change. Motivation barriers included a sense of futility in treating patients with AUD and stigmas associated with alcohol use. Evidence-based interventions included multi-modal provider education, a standardized treatment algorithm and order set, selection of clinical champions, and clarification of roles among providers on the team.

Conclusions

A large evidence-practice gap exists for the treatment of AUD with Naltrexone, and the ED visit is a missed opportunity for intervention. ED providers are optimistic about implementing AUD treatment in the ED but described many barriers, especially related to knowledge, clarification of roles, and stigma associated with AUD. Applying a formal implementation science approach guided by the Behavior Change Wheel allowed us to transform qualitative interview data into evidence-based interventions for the implementation of an ED-based program for the treatment of AUD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07862-1.

Clinical characteristics and health outcomes in patients with alcohol withdrawal syndrome: an observational study from Oman

BACKGROUND

Globally, alcohol withdrawal syndrome (AWS) is considered a serious medical diagnosis associated with increasing morbidity and mortality. Little information has been reported on the scope of the problem in Oman.

OBJECTIVE

Study clinical characteristics, management, quality of care, and health outcomes of patients managed for AWS.

DESIGN

Retrospective medical record review.

SETTINGS

University hospital.

PATIENTS AND METHODS

The study included all patients with AWS admitted from 1 October 2019 to 30 September 2020. We collected demographic and clinical characteristics and did a univariate analysis of factors related to 90-day readmission.

MAIN OUTCOME MEASURES

Length of hospital stay, 90-day read-mission, referral rate to alcohol rehabilitation center.

SAMPLE SIZE AND CHARACTERISTICS

150 male patients with median (IQR) age of 39.5 (32-48) years.

RESULTS

Most patients (70.7%, n=106) were smokers and 44 (29.3%) had a history of drug abuse. The average length of hospital stay was 2.3 (0.9-4.6) days. Approximately 9% of total hospital bed days were used to care for patients with AWS. Chronic liver disease (35.3%), diabetes mellitus (24.7%), and hypertension (24.0%) were common among AWS patients. The 90-day readmission rate (32.7%) was high, and there was low referral to alcohol rehabilitation (16.7%). Diabetes and epilepsy were associated with 90-day readmission.

CONCLUSION

AWS is an important diagnosis that represents an important burden on acute medical services. Establishing a drug and alcohol service in our institution is an essential step to optimise care for patients with alcohol-related disorders.

LIMITATIONS

Retrospective, so unable to collect data on manifestations of AWS such as delirium tremens, which is the most severe form of AWS. Also, the reason for the lack of referral to an outpatient alcohol rehabilitation program was not apparent.

CONFLICT OF INTEREST

None.

Prevention of alcohol withdrawal seizure recurrence and treatment of other alcohol withdrawal symptoms in the emergency department: a rapid review

Background

Patients who experience harms from alcohol and other substance use often seek care in the emergency department (ED). ED visits related to alcohol withdrawal have increased across the world during the COVID-19 pandemic. ED clinicians are responsible for risk-stratifying patients under time and resource constraints and must reliably identify those who are safe for outpatient management versus those who require more intensive levels of care. Published guidelines for alcohol withdrawal are largely limited to the primary care and outpatient settings, and do not provide specific guidance for ED use. The purpose of this review was to synthesize published evidence on the treatment of alcohol withdrawal syndrome in the ED.

Methods

We conducted a rapid review by searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (1980 to 2020). We searched for grey literature on Google and hand-searched the conference abstracts of relevant addiction medicine and emergency medicine professional associations (2015 to 2020). We included interventional and observational studies that reported outcomes of clinical interventions aimed at treating alcohol withdrawal syndrome in adults in the ED.

Results

We identified 13 studies that met inclusion criteria for our review (7 randomized controlled trials and 6 observational studies). Most studies were at high/serious risk of bias. We divided studies based on intervention and summarized evidence narratively. Benzodiazepines decrease alcohol withdrawal seizure recurrence and treat other alcohol withdrawal symptoms, but no clear evidence supports the use of one benzodiazepine over another. It is unclear if symptom-triggered benzodiazepine protocols are effective for use in the ED. More evidence is needed to determine if phenobarbital, with or without benzodiazepines, can be used safely and effectively to treat alcohol withdrawal in the ED. Phenytoin does not have evidence of effectiveness at preventing withdrawal seizures in the ED.

Conclusions

Few studies have evaluated the safety and efficacy of pharmacotherapies for alcohol withdrawal specifically in the ED setting. Benzodiazepines are the most evidence-based treatment for alcohol withdrawal in the ED. Pharmacotherapies that have demonstrated benefit for treatment of alcohol withdrawal in other inpatient and outpatient settings should be evaluated in the ED setting before routine use.

Electroencephalographic neurofeedback as a tool for reducing harm and risk associated with alcohol use disorder: A critical review

ISSUES

Alcohol use disorder (AUD) causes the highest harms around the world. Many people use alcohol to reduce stress and anxiety, considered as risk factors for AUD. Chronic alcohol use leads to changes in the reward system and the high level of stress may exacerbate neuroendocrine responses. Electroencephalographic (EEG) neurofeedback shows reduction of stress, anxiety and alcohol abuse and it could be an important tool for reducing harm and risk associated with AUD. The aim of this paper is to review the studies that investigated the effects of EEG neurofeedback in subjects with AUD and it proposes to discuss this intervention as a tool for reducing harm and risk in AUD.

APPROACH

Medline, PsycINFO and LILACS databases were searched and appropriated terms were used. Inclusion criterion was adopted. The year of publication was not limited because of the scarce number of studies. Eighty-two papers returned and eight were included. A critical review was conducted.

KEY FINDINGS

Most of the papers analysed used the alpha/theta protocol to reduce the 'hyperexcitation' of the nervous system. This protocol provides relaxation, decreases anxiety or stress, prevents alcohol relapse, maintains abstinence and increases the feeling of well-being.

IMPLICATIONS

EEG neurofeedback has important effects on AUD and anxiety or stress. Studies reinforce the use of EEG neurofeedback as an alternative tool for reducing harm and risk in AUD.

CONCLUSION

EEG neurofeedback is an intervention to treat AUD, specifically, to reduce harm and risk. However, more randomised studies are necessary to consolidate the effectiveness of the technique.