Program Curbs Alcohol Detox Admissions

Marcia Frellick

March 27, 2019

NATIONAL HARBOR, Maryland — An outpatient intervention for patients experiencing alcohol withdrawal syndrome improves outcomes — decreasing admissions and readmissions and shortening hospital stays — while keeping patients safe, new research from a Veterans Affairs (VA) hospital indicates.

Before this program, "we were basically admitting every single person who presented to the emergency department for detox," said Robert Patrick, MD, from the Louis Stokes Veterans Affairs Medical Center in Cleveland.

Such admissions are common, he said here at the Society of Hospital Medicine 2019 Annual Meeting. In 2017, 33,000 patients were admitted to a VA facility with alcohol withdrawal syndrome.

"We were doing a symptom-guided regimen with lorazepam and diazepam," he explained. Every 2 hours, nurses would titrate the medication on the basis of symptoms assessed with the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score.

The problem is that the patients like to have these controlled substances and the "nurses like to give them because the patients stay quiet," Patrick told Medscape Medical News. "We saw a lot of gaming of the system."

Patrick and his coinvestigator — Laura Brown, MD, also from Louis Stokes VA — conducted a chart review and identified 424 patients who were at low risk for severe withdrawal and good candidates for outpatient management. They modified a screening algorithm validated by a team from the University of North Carolina School of Medicine (J Gen Intern Med. 2014;29:587-593).

"The two critical factors for screening in the ED for us are a sober CIWA score and a documented history of complicated withdrawal," Patrick said.

The pair trained nurses to get a more accurate CIWA score. They then added vital sign criteria to the score as a threshold for medication administration: a systolic blood pressure greater than 165 mm Hg and a heart rate greater than 100 beats per minute.

"That dropped the number of meds quite a bit," Patrick reported. Prior to implementation of the protocol, patients were getting about 2.9 medication doses per admission, but that dropped to 1.8 doses.

In addition, the amount of time spent on the CIWA protocol decreased from 2.8 days to 1.6 days, "which dropped the nursing workload significantly," he said. And "we cut the number of notes they were doing by almost two-thirds."

The pair also developed a dashboard in the electronic health record system. Each day, they looked at a patient's status and called the attending physician on the floor to discuss whether that patient needed to stay another day or could go home.

If you don't shut down the candy store, patients will just keep coming back.

To decrease the use of benzodiazepines, patients discharged home got enough gabapentin for 5 days and enough lorazepam for 3 days.

"If you don't shut down the candy store, patients will just keep coming back," he said.

In the 8 months after the changes, admissions for alcohol withdrawal syndrome were down by 54% — from 24 to 11 per month. All-cause hospital-wide readmissions went from four per month to less than one per month, and average length of stay was reduced by 24% — from 2.9 to 2.2 days.

Worries About Relapse

There was initial skepticism from ED physicians about letting patients with alcohol withdrawal syndrome go home for fear that they would fall through the cracks, relapse, and come right back.

To address those worries, Patrick and Brown developed an e-consult system so that they were alerted every time a patient was sent home from the ED instead of being admitted. For the following 3 days, one of them called that patient to check on status and talk about maintenance.

Often, patients were asked whether they knew where the nearest Alcoholics Anonymous meeting was. And sometimes the investigators discussed enrollment in an outpatient program to help the patient stay sober.

Long calls could take 15 minutes, but most calls were 3 to 5 minutes, Patrick said.

Of the more than 80 patients who participated in this outpatient detox program, "we didn't have a single one bounce back to the hospital," he reported.

The pair shared notes on the progress of these patients with the referring physician to reinforce the safety and effectiveness of the program.

Veterans are often difficult to reach by phone, but Patrick and Brown were able to connect with almost 90% of them by calling family members and homeless shelters and trying several times a day.

Maintenance of sobriety is a component of the package of interventions, but this project was designed to address withdrawal, not sobriety, Patrick emphasized.

"Although we want the patients to stay sober, what we want more is for them not to die as part of their alcohol withdrawal," he said. Some are ready to quit and some aren't, he pointed out.

Buy-in from the ED is great, but it is not necessary. "You can do it just within your hospitalist group," he pointed out.

There are currently three other VA sites implementing the program, he reported.

Although we want the patients to stay sober, what we want more is for them not to die as part of their alcohol withdrawal.

This is a common problem and these preliminary data are "impressive," said Benji Mathews, MD, from the University of Minnesota in Minneapolis, who is director of research and innovation for the conference.

Although this protocol was implemented at a VA facility, it could be widely adapted, he told Medscape Medical News.

"The results show promise that hospitals could reduce costs and keep patients safe. I think it's pretty remarkable," Mathews said.

"This operationalizes what we already know," said Jerry Hu, DO, PharmD, an internist with the United States Army stationed at Fort Bragg, North Carolina, who said he agrees that the protocol has wide potential.

"The goal is to reduce admissions," Hu told Medscape Medical News. This study shows that "we can use what we already have to keep these patients out of the hospital."

Patrick, Mathews, and Hu have disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2019 Annual Meeting: Abstract 598180. Presented March 26, 2019.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick



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