Symptom-triggered Vs Fixed Dosing Schedules in the Management of Alcohol Withdrawal Jay Murdoch Alcohol Nurse Specialist.

Symptom-triggered Vs Symptom-triggered Vs Fixed Dosing Schedules in Fixed Dosing Schedules in the Management of the Management of Alcohol WithdrawalAlcohol Withdrawal

Jay MurdochJay Murdoch

Alcohol Nurse SpecialistAlcohol Nurse Specialist

BackgroundBackground

The number of dependant drinkers in The number of dependant drinkers in England stands at 1.6 millionEngland stands at 1.6 million

The cost to the NHS is £2.7 Billion every The cost to the NHS is £2.7 Billion every year and is set to rise to £3.7 Billionyear and is set to rise to £3.7 Billion

Alcohol withdrawal often causes Alcohol withdrawal often causes significant management problems and significant management problems and complicates the management of a wide complicates the management of a wide variety of concurrent conditions variety of concurrent conditions

The number of hospital admissions was The number of hospital admissions was 1.1 million in 2009/2010, a 100% 1.1 million in 2009/2010, a 100% increase since 2002/03.increase since 2002/03.

Background ContinuedBackground Continued

Although alcohol use and abuse are Although alcohol use and abuse are common among inpatients, many common among inpatients, many patients are inadequately assessed and patients are inadequately assessed and treated for alcohol withdrawal treated for alcohol withdrawal

Excessive drinking is currently the Excessive drinking is currently the second greatest risk to public health in second greatest risk to public health in developed countries developed countries

Although most of that risk is avoidable Although most of that risk is avoidable the risk is clearly apparent with the large the risk is clearly apparent with the large number of hospital admissions every number of hospital admissions every year year

The ProjectThe Project

Is commissioned as part of Is commissioned as part of Manchester’s Alcohol StrategyManchester’s Alcohol Strategy

IBA work with harmful and IBA work with harmful and hazardous drinkershazardous drinkers

Work with dependant drinkersWork with dependant drinkers Reducing attendance rate of Reducing attendance rate of

‘frequent fliers’‘frequent fliers’ Alcohol Withdrawal PolicyAlcohol Withdrawal Policy

Part 1 AimsPart 1 Aims

Pre intervention auditPre intervention audit Identify current practiceIdentify current practice Identify any short fallsIdentify any short falls Compare current practice to Compare current practice to

national guidancenational guidance Identify a need for change in Identify a need for change in

practicepractice

Part 2 AimsPart 2 Aims

Intervention stageIntervention stage Implementation of an Integrated Care Implementation of an Integrated Care

Pathway (ICP)Pathway (ICP) Incorporating Assessment tool (CIWA Incorporating Assessment tool (CIWA

score)score) Management pathwaysManagement pathways Standardise management of alcohol Standardise management of alcohol

withdrawalwithdrawal Implementation of a symptom-triggered Implementation of a symptom-triggered

approach to careapproach to care

Part 3 AimsPart 3 Aims

Post intervention audit- Complete Post intervention audit- Complete audit cycleaudit cycle

Has the intervention been Has the intervention been successful?successful?

Has practice improved?Has practice improved? Has patient care improved?Has patient care improved? Has staff satisfaction improved?Has staff satisfaction improved? Compare findings from both auditsCompare findings from both audits

Audit ToolAudit Tool

Was the alcohol ICP used in the management of this patient?Was the alcohol ICP used in the management of this patient? Important to identify if the Trust guidelines are being metImportant to identify if the Trust guidelines are being met Number of days to complete detox?Number of days to complete detox?

Important to compare pre ICP and post ICP to note any improvementImportant to compare pre ICP and post ICP to note any improvement How much Chlordiazepoxide was administered?How much Chlordiazepoxide was administered?

Important to compare pre ICP and post ICP to note any improvementImportant to compare pre ICP and post ICP to note any improvement If ICP not commenced. Was PRN medication utilised?If ICP not commenced. Was PRN medication utilised?

This will identify if predetermined dosing regimes are used are staff trying to alleviate This will identify if predetermined dosing regimes are used are staff trying to alleviate further symptoms with as required medicationfurther symptoms with as required medication

If PRN medication was used was it identified in the notes why?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 This will highlight the need for CIWA scoring system that is part of ICP to improve assessment and documentationassessment and documentation

What drug is used in the detox process?What drug is used in the detox process?Will see if we are using the best available pharmacology to manage this groupWill see if we are using the best available pharmacology to manage this group

Is there consistency with prescribing?Is there consistency with prescribing?This will identify any problems with medical prescribing. Are the medicines prescribed in This will identify any problems with medical prescribing. Are the medicines prescribed in proper place? Are all areas of Kardex complete?proper place? Are all areas of Kardex complete?

Did anyone develop delirium or seizure activity following commencement on a Did anyone develop delirium or seizure activity following commencement on a detox?detox?This will help identify differences between symptom-triggered management and This will help identify differences between symptom-triggered management and predetermined dosing.predetermined dosing.

Sample GroupsSample Groups

Both groups contained fifty Both groups contained fifty patientspatients

Convenience sampleConvenience sample All patients completed a detox in All patients completed a detox in

hospital hospital All patients All patients were alcohol were alcohol

dependent within DSMV-IV and ICD dependent within DSMV-IV and ICD 10 classifications10 classifications

DiscussionDiscussion

Pre ICP Pre ICP implementation implementation PracticePractice No consistency with prescribingNo consistency with prescribing No official guidelinesNo official guidelines Prophylactic dosing regimesProphylactic dosing regimes Medication not individually tailored Medication not individually tailored

to patientto patient Non-licensed medication being usedNon-licensed medication being used No assessment scoring to measure No assessment scoring to measure

withdrawal severitywithdrawal severity

Clinical IncidentsClinical Incidents

As a background Clinical incidents As a background Clinical incidents involving alcohol were involving alcohol were investigatedinvestigated

Coroners courtCoroners court Identified a need for changeIdentified a need for change Multiple incidents involving Multiple incidents involving

alcoholalcohol

No of days to complete No of days to complete a detoxa detox

Pre change Pre change average number average number of days to of days to complete audit complete audit was 6.36 dayswas 6.36 days

Post change Post change average number average number of days to of days to complete audit complete audit was 2.48 days was 2.48 days

How much How much Chlordiazepoxide was Chlordiazepoxide was administered?administered?

Pre implemenation-Average Pre implemenation-Average number of milligrams to number of milligrams to complete an inpatient detox complete an inpatient detox was 563.3 mg. was 563.3 mg.

40% were given PRN 40% were given PRN medication but in only 10% of medication but in only 10% of these (2 cases) was the reason these (2 cases) was the reason for this documentedfor this documented

Six of the prescriptions did not Six of the prescriptions did not use Chlordiazepoxide but used use Chlordiazepoxide but used other medication.other medication.

Post implementation- Average Post implementation- Average number of milligrams of number of milligrams of Chlordiazepoxide to complete Chlordiazepoxide to complete an inpatient detox was 167.2 an inpatient detox was 167.2 mg.mg.

Chlordiazepoxide was the only Chlordiazepoxide was the only drug useddrug used

5 patients required no 5 patients required no ChlordiazepoxideChlordiazepoxide

Consistency With Consistency With PrescribingPrescribingPre InterventionPre Intervention No uniformityNo uniformity Differing regimes Differing regimes

usedused Multiple prescribing Multiple prescribing

errors notederrors noted Administration Administration

errors notederrors noted

Post InterventionPost Intervention All patients All patients

prescribed the same prescribed the same medication medication

All prescribed All prescribed appropriately appropriately

All used symptom-All used symptom-triggered approach triggered approach to careto care

Some administration Some administration errors still errors still

Development of Development of further withdrawal further withdrawal phenomena phenomena 14 patients in the pre-14 patients in the pre-

intervention group developed intervention group developed severe signs of withdrawal severe signs of withdrawal following commencement on a following commencement on a detoxdetox

Compared to 3 patients in the Compared to 3 patients in the post-intervention group post-intervention group

Staff SatisfactionStaff Satisfaction

A questionnaire was utilised using A questionnaire was utilised using open and closed questionsopen and closed questions

Was sent to 200 staff Was sent to 200 staff 138 were returned138 were returned Staff satisfaction was noted to improveStaff satisfaction was noted to improve Staff had noted improvement in Staff had noted improvement in

patient carepatient care DocumentationDocumentation Time managementTime management ConfidenceConfidence

DocumentationDocumentation

There are clear improvements in There are clear improvements in documentationdocumentation

This was needed as highlighted from Coroners This was needed as highlighted from Coroners Court and other clinical incidentsCourt and other clinical incidents

All clinicians now documenting withdrawal All clinicians now documenting withdrawal symptoms in same documentsymptoms in same document

User friendly document allowing clinical staff User friendly document allowing clinical staff to score the symptoms therefore all clinicians to score the symptoms therefore all clinicians involved with patient can identify what signs involved with patient can identify what signs and symptoms the patient has been portrayingand symptoms the patient has been portraying

Much easier to rule out Wernicke’s Much easier to rule out Wernicke’s encephalopathy or Anxiety related disorders encephalopathy or Anxiety related disorders being mismanaged with Chlordiazepoxide.being mismanaged with Chlordiazepoxide.

CostingCosting

The average cost of an inpatient stay is £300 The average cost of an inpatient stay is £300 per nightper night

The average cost to complete an inpatient The average cost to complete an inpatient detox before symptom-triggered approach to detox before symptom-triggered approach to care was £1,908. care was £1,908.

Compares to £744 for post intervention Compares to £744 for post intervention group.group.

Further costing reductions could be noteed in Further costing reductions could be noteed in pharmacy costs.pharmacy costs.

The printing costs for 3000 booklets/ICP’s is The printing costs for 3000 booklets/ICP’s is ££1191.721191.72

CostingCosting

0100002000030000400005000060000700008000090000

100000

Cost in pounds

Pre ICP Post ICP

Pre-and-post ICP

Cost of detox for 50 patients

Cost of detox for 50 patients

Mann-Whitney TestMann-Whitney Test

Mann-Whitney parametric test Mann-Whitney parametric test used used

P-value is 0.0001P-value is 0.0001

ConclusionsConclusions

A symptom-triggered approach is A symptom-triggered approach is appropriate in the management of appropriate in the management of alcohol withdrawalalcohol withdrawal

Improves careImproves care Improves treatment durationImproves treatment duration Decrease in medication requiredDecrease in medication required Harmonised clinical managementHarmonised clinical management Improved documentationImproved documentation Staff satisfaction notedStaff satisfaction noted Significant Costing differences Significant Costing differences

ReferencesReferences

Alcohol Concern (2010) Investing in Alcohol Treatments: Reducing Costs and Alcohol Concern (2010) Investing in Alcohol Treatments: Reducing Costs and Saving. Alcohol Concern. London.Saving. Alcohol Concern. London.

Alcohol Concern (2011) Making Alcohol a Health Priority- Opportunities to Alcohol Concern (2011) Making Alcohol a Health Priority- Opportunities to Reduce alcohol Harms and Rising Costs. Alcohol Concern. London.Reduce alcohol Harms and Rising Costs. Alcohol Concern. London.

Foy A., Kay J., and Taylor A. (2002) The course of alcohol withdrawal in a Foy A., Kay J., and Taylor A. (2002) The course of alcohol withdrawal in a general hospital. QJM Vol 90 pp. 253-261.general hospital. QJM Vol 90 pp. 253-261.

Kaner E. (2010) Brief interventions against excessive alcohol consumption. In: Kaner E. (2010) Brief interventions against excessive alcohol consumption. In: Oxford Textbook of Medicine. Oxford University Press, Oxford, pp. 1334-1336Oxford Textbook of Medicine. Oxford University Press, Oxford, pp. 1334-1336

NICE (2010) Alcohol Use Disorders: Diagnosis and clinical management of NICE (2010) Alcohol Use Disorders: Diagnosis and clinical management of alcohol related physical complications. London. National Institute for Health alcohol related physical complications. London. National Institute for Health and Clinical Excellence.and Clinical Excellence.

NICE (2010b) Alcohol Use Disorders: Sample Chlordiazepoxide dosing NICE (2010b) Alcohol Use Disorders: Sample Chlordiazepoxide dosing regimens for use in managing alcohol withdrawal. London. National Institute regimens for use in managing alcohol withdrawal. London. National Institute for Health and Clinical Excellencefor Health and Clinical Excellence

Repper-Delisi J., Stern T.A., Mitchell M., Lussier-cushing M, Lakatose Repper-Delisi J., Stern T.A., Mitchell M., Lussier-cushing M, Lakatose B.,Frichione G. et al. (2008) B.,Frichione G. et al. (2008) Successful Implementation of an Alcohol- Successful Implementation of an Alcohol- Withdrawal Pathway in a General Hospital. Psychosomatics Vol 49(4) pp. Withdrawal Pathway in a General Hospital. Psychosomatics Vol 49(4) pp. 292-299.292-299.

Williams S., Brown A,. Patton R., Crawford M. and Touquet R. (2004) The half-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 life of the ‘teachable moment’ for alcohol misusing patients in the Emergency Department. Drug and Alcohol Dependence Vol 77 pp. 205-208. Department. Drug and Alcohol Dependence Vol 77 pp. 205-208.