1
|
Suárez-Cuenca JA, Toledo-Lozano CG, Espinosa-Arroyo MD, Vázquez-Aguirre NA, Fonseca-González GT, Garro-Almendaro K, Melchor-López A, García-López VH, Ortiz-Matamoros A, Ortega-Rosas T, Alcaraz-Estrada SL, Mondragón-Terán P, García S. Diagnostic Performance of AST Scale in Mexican Male Population for Alcohol Withdrawal Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159208. [PMID: 35954565 PMCID: PMC9367724 DOI: 10.3390/ijerph19159208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Juan Antonio Suárez-Cuenca
- Internal Medicine Department, Hospital General Xoco, SEDESA, Mexico City 03330, Mexico; (J.A.S.-C.); (M.D.E.-A.); (N.A.V.-A.); (K.G.-A.); (A.M.-L.)
- Department of Clinical Research, Centro Médico Nacional “20 de Noviembre”, ISSSTE, Mexico City 03229, Mexico; (A.O.-M.); (T.O.-R.)
| | - Christian Gabriel Toledo-Lozano
- Department of Clinical Research, Centro Médico Nacional “20 de Noviembre”, ISSSTE, Mexico City 03229, Mexico; (A.O.-M.); (T.O.-R.)
- Correspondence: (C.G.T.-L.); (S.G.); Tel.: +52-551-956-2089 (C.G.T.-L.); +52-555-437-7491 (S.G.)
| | - Maryjose Daniela Espinosa-Arroyo
- Internal Medicine Department, Hospital General Xoco, SEDESA, Mexico City 03330, Mexico; (J.A.S.-C.); (M.D.E.-A.); (N.A.V.-A.); (K.G.-A.); (A.M.-L.)
| | - Nallely Alejandra Vázquez-Aguirre
- Internal Medicine Department, Hospital General Xoco, SEDESA, Mexico City 03330, Mexico; (J.A.S.-C.); (M.D.E.-A.); (N.A.V.-A.); (K.G.-A.); (A.M.-L.)
| | | | - Karen Garro-Almendaro
- Internal Medicine Department, Hospital General Xoco, SEDESA, Mexico City 03330, Mexico; (J.A.S.-C.); (M.D.E.-A.); (N.A.V.-A.); (K.G.-A.); (A.M.-L.)
| | - Alberto Melchor-López
- Internal Medicine Department, Hospital General Xoco, SEDESA, Mexico City 03330, Mexico; (J.A.S.-C.); (M.D.E.-A.); (N.A.V.-A.); (K.G.-A.); (A.M.-L.)
| | | | - Abril Ortiz-Matamoros
- Department of Clinical Research, Centro Médico Nacional “20 de Noviembre”, ISSSTE, Mexico City 03229, Mexico; (A.O.-M.); (T.O.-R.)
| | - Tania Ortega-Rosas
- Department of Clinical Research, Centro Médico Nacional “20 de Noviembre”, ISSSTE, Mexico City 03229, Mexico; (A.O.-M.); (T.O.-R.)
| | | | - Paul Mondragón-Terán
- Coordination of Research, Centro Médico Nacional “20 de Noviembre”, ISSSTE, Mexico City 03229, Mexico;
| | - Silvia García
- Department of Clinical Research, Centro Médico Nacional “20 de Noviembre”, ISSSTE, Mexico City 03229, Mexico; (A.O.-M.); (T.O.-R.)
- Correspondence: (C.G.T.-L.); (S.G.); Tel.: +52-551-956-2089 (C.G.T.-L.); +52-555-437-7491 (S.G.)
| |
Collapse
|
2
|
Lin Y, Dong X, Sun R, Wu J, Tian L, Rao D, Zhang L, Yang K. Migratory birds-one major source of environmental antibiotic resistance around Qinghai Lake, China. THE SCIENCE OF THE TOTAL ENVIRONMENT 2020; 739:139758. [PMID: 32540654 PMCID: PMC7260505 DOI: 10.1016/j.scitotenv.2020.139758] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/25/2020] [Accepted: 05/25/2020] [Indexed: 05/26/2023]
Abstract
Migratory birds are potential transmitters of bacterial antibiotic resistance. However, their role in the environmental dissemination of bacterial antibiotic resistance and the extent of their impact on the environment are not yet clear. Qinghai Lake is one of the most important breeding and stopover ground for the migratory birds along the Central Asian Flyway. Here, we investigated the bacterial antibiotic resistance in the environment and among the migratory birds around the lake. The results of culture-based analysis of bacterial antibiotic resistance, quantitative PCR and metagenomic sequencing indicate that migratory birds are one major source of bacterial antibiotic resistance in the environment around Qinghai Lake. Network analysis reveals the co-occurrence patterns of antibiotic resistance genes (ARGs) and bacterial genera. Genetic co-localization analysis suggests high co-selection potential (with incidence of 35.8%) among different ARGs, but limited linkage (with incidence of only 3.7%) between ARGs and biocide/metal resistance genes (BMRGs). The high genetic linkage between ARGs and mobile genetic elements (MGEs) is still largely confined to the bacterial community in migratory birds (accounting for 96.0% of sequencing reads of MGE-linked ARGs), which indicates limited horizontal transfer of ARGs to the environment. Nevertheless, the antibiotic resistance determinants carried by migratory birds and their specific genetic properties (high co-selection and mobility potential of the ARGs) remind us that the role of migratory birds in the environmental dissemination of bacterial antibiotic resistance deserves more attention.
Collapse
Affiliation(s)
- Yufei Lin
- Department of Pharmaceutical & Biological Engineering, School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Xiaohong Dong
- Department of Pharmaceutical & Biological Engineering, School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Rui Sun
- Tianjin Academy of Eco-Environment Sciences, Tianjin 300191, China
| | - Jiao Wu
- Department of Pharmaceutical & Biological Engineering, School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Lejin Tian
- Department of Pharmaceutical & Biological Engineering, School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Dawei Rao
- Department of Pharmaceutical & Biological Engineering, School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Lihua Zhang
- Department of Pharmaceutical & Biological Engineering, School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Kun Yang
- Department of Pharmaceutical & Biological Engineering, School of Chemical Engineering, Sichuan University, Chengdu 610065, China.
| |
Collapse
|
3
|
Butterfield M, Thorne-Humphrey L, Suzuki J, Herschenhous N. Evaluation of a Novel Protocol for Assessment and Treatment of Alcohol Withdrawal Syndrome in Psychiatric Inpatients. Am J Addict 2020; 29:500-507. [PMID: 32490573 DOI: 10.1111/ajad.13058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 04/04/2020] [Accepted: 05/02/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the high incidence of alcohol withdrawal syndrome (AWS) in psychiatric inpatients, standardized methods for assessing and treating AWS have been studied only once before in this population. We evaluated a novel AWS assessment and treatment protocol designed for psychiatric inpatients. METHODS This retrospective cohort study evaluated outcomes before and after implementation of the protocol. We collected consecutive data on patients (N = 138) admitted to inpatient psychiatric units at a single center. Participants were patients admitted for nonsubstance-related psychiatric reasons, who were also at risk for developing AWS. Those who developed AWS were treated with either (a) treatment as usual (TAU) or (b) a novel standardized protocol. The primary outcome was duration of benzodiazepine treatment for symptoms of alcohol withdrawal. Secondary outcomes included cumulative benzodiazepine dose administered, treatment duration, and incidence of complications. RESULTS Of 138 participants, 83 received TAU and 55 were assessed and treated with the novel protocol. Median duration of benzodiazepine treatment following protocol implementation was 19.7 hours (interquartile range [IQR], 0-46) prior to implementation (TAU) and 0 hours (IQR, 0-15) following protocol implementation (protocol group) (P < .0001). Median benzodiazepine dose (in diazepam equivalents) administered to participants was 30 mg (IQR, 0-65) for TAU and 5 mg (IQR, 0-30) for the protocol group (P < .001). Adverse events before and after implementation occurred in 4.8% and 0%, respectively (P = .15). CONCLUSION AND SCIENTIFIC SIGNIFICANCE This study provides preliminary evidence for the efficacy and safety of a novel standardized AWS protocol for psychiatric inpatients. This is the first known study assessing an AWS assessment and treatment protocol designed for psychiatric inpatients. (Am J Addict 2020;29:500-507).
Collapse
Affiliation(s)
- Michael Butterfield
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lucas Thorne-Humphrey
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joji Suzuki
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Nicole Herschenhous
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| |
Collapse
|
4
|
Nejad S, Nisavic M, Larentzakis A, Dijkink S, Chang Y, Levine AR, de Moya M, Velmahos G. Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients-A Retrospective Comparison Study. PSYCHOSOMATICS 2020; 61:327-335. [PMID: 32199629 DOI: 10.1016/j.psym.2020.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/17/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Alcohol withdrawal syndrome (AWS) in surgical trauma patients is associated with significant morbidity and mortality. Benzodiazepines, commonly used for withdrawal management, pose unique challenges in this population given the high prevalence of head trauma and delirium. Phenobarbital is an antiepileptic drug that offers a viable alternative to benzodiazepines for AWS treatment. METHODS This is a retrospective chart review of patients with active alcohol use disorder who presented to a level 1 trauma center over a 4-year period and required medication-assisted management for AWS. The primary outcome variable examined was the development of AWS and associated complications. Additional outcomes measured included hospital length of stay, mortality, and medication-related adverse events. RESULTS Of the 85 patients in the study sample, 52 received a fixed-dose benzodiazepine-based protocol and 33 received phenobarbital-based protocol. In the benzodiazepine-based protocol group, 25 patients (48.2%) developed AWD and 38 (73.1%) developed uncomplicated AWS, as compared to 0 patients in the phenobarbital-based protocol (P = 0.0001). There were 10 (19.2%) patients with medication adverse side effects in the benzodiazepine-based protocol group versus 0 patients in the phenobarbital-based protocol group. There were no statically significant differences between the 2 groups as pertains to rates of other AWS-related complications, patient mortality, or length of stay. CONCLUSION The use of a phenobarbital-based protocol in trauma patients with underlying active alcohol use disorder resulted in a statistically significant decrease in the incidence of AWD and uncomplicated AWS secondary to AWS when compared to patients treated with a fixed-dose benzodiazepine-based protocol.
Collapse
Affiliation(s)
- Shamim Nejad
- Division of Psychosocial Oncology - Swedish Cancer Institute, Swedish Medical Center, Seattle, WA
| | - Mladen Nisavic
- Addiction Consult Service, Avery D. Weismann, Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA.
| | - Andreas Larentzakis
- First Department of Propaedeutic Surgery, Hippokration General Hospital of Athens, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Suzan Dijkink
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Yuchiao Chang
- Trauma, Emergency Surgery and Surgical Critical Care Service, Massachusetts General Hospital, Boston, MA
| | - Alexander R Levine
- Assistant Professor of Pharmacy Practice, University of Saint Joseph School of Pharmacy, Department of Pharmacy Practice, Hartford, CT
| | - Marc de Moya
- Division of Trauma and Acute Care Surgery, Milton and Lidy Lunda/Charles Aprahamian Professor of Trauma Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - George Velmahos
- Trauma, Emergency Surgery and Surgical Critical Care Service, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
5
|
Development of an alcohol withdrawal risk stratification tool based on patients referred to an addiction liaison nursing service in Glasgow. DRUGS AND ALCOHOL TODAY 2019. [DOI: 10.1108/dat-02-2019-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to develop an alcohol withdrawal syndrome risk stratification tool that could support the safe discharge of low risk patients from the emergency department.
Design/methodology/approach
A retrospective cohort study that included all patients referred to the acute addiction liaison nursing service over one calendar month (n=400, 1–30 April 2016) was undertaken. Bivariate and multivariate modelling identified the significant variables that supported the prediction of severe alcohol withdrawal syndrome (SAWS) in the cohort population.
Findings
The Glasgow Modified Alcohol Withdrawal Scale (GMAWS), hours since last drink, fast alcohol screening test (FAST) and systolic blood pressure correctly identified 89 per cent of patients who developed SAWS and 84 per cent of patients that did not. Increasing each component by a score of one is associated with an increase in the odds of SAWS by a factor of 2.76 (95% CI 2.21, 3.45), 1.31 (95% CI 1.24, 1.37), 1.30 (95% CI 1.08, 1.57) and 1.22 (95% CI 1.10, 1.34), respectively.
Research limitations/implications
The research was conducted in a single healthcare system that had a high prevalence of alcohol dependence syndrome (ADS). Second, the developed risk stratification tool was unable to guarantee no risk and lastly, the FAST score previously aligned to severe ADS may have influenced the patients highest GMAWS score.
Practical implications
The tool could help redesign the care pathway for patients who attend the emergency department at risk of SAWS and link low risk patients with community alcohol services better equipped to deal with their physical and psychological needs short and long term supporting engagement, abstinence and prolongation of life.
Originality/value
The tool could help redesign the care pathway for emergency department patients at low risk of SAWS and link them with community alcohol services better equipped to deal with their physical and psychological needs, short and long term, supporting engagement, abstinence and prolongation of life.
Collapse
|
6
|
Nisavic M, Nejad SH, Isenberg BM, Bajwa EK, Currier P, Wallace PM, Velmahos G, Wilens T. Use of Phenobarbital in Alcohol Withdrawal Management - A Retrospective Comparison Study of Phenobarbital and Benzodiazepines for Acute Alcohol Withdrawal Management in General Medical Patients. PSYCHOSOMATICS 2019; 60:458-467. [PMID: 30876654 DOI: 10.1016/j.psym.2019.02.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Benzodiazepine-based protocols offer a standard of care for management of alcohol withdrawal, though they may not be safe or appropriate for all patients. Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment, though existing research offers only modest guidance to the safety and effectiveness of phenobarbital in managing alcohol withdrawal syndrome (AWS) in general hospital settings. METHODS To compare clinical effectiveness of phenobarbital versus benzodiazepines in managing symptoms of alcohol withdrawal, we conducted a retrospective chart review of 562 patients admitted over a 2-year period to a general hospital and treated for AWS. The development of AWS-related complications (seizures, alcoholic hallucinosis, and alcohol withdrawal delirium) post-treatment initiation was the primary outcome examined in both treatment groups. Additional outcomes measured included hospital length of stay, intensive care unit (ICU) admission rates/length of stay, medication-related adverse events, and discharge against medical advice. RESULTS Despite being significantly more likely to have a history of prior complications related to AWS (including seizures and delirium), patients initiated on phenobarbital (n = 143) had overall similar primary and secondary treatment outcomes to those in the benzodiazepine treatment protocol (n = 419). Additionally, a subset of patients (n = 16) initially treated with benzodiazepines displayed signs of treatment nonresponse, including significantly higher rates of AWS-related delirium and ICU admission rates, but were well-managed following transition to the phenobarbital protocol. CONCLUSION The data from this retrospective chart review lend further support to effectiveness and safety of phenobarbital for the treatment and management of AWS. Further randomized controlled trials are warranted.
Collapse
Affiliation(s)
- Mladen Nisavic
- Addiction Consult Service, Avery D. Weismann, Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA.
| | - Shamim H Nejad
- Division of Psychosocial Oncology - Swedish Cancer Institute, Swedish Medical Center, Seattle, WA
| | - Benjamin M Isenberg
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD Massachusetts General Hospital, Boston, MA
| | - Ednan Khalid Bajwa
- Pulmonary & Critical Care Unit, Massachusetts General Hospital, Boston, MA
| | - Paul Currier
- Pulmonary & Critical Care Unit, Massachusetts General Hospital, Boston, MA
| | | | - George Velmahos
- Trauma, Emergency Surgery and Surgical Critical Care Service, Massachusetts General Hospital, Boston, MA
| | - Timothy Wilens
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD Massachusetts General Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| |
Collapse
|
7
|
Attfield J, Brown S, Carter T, Callaghan P. A retrospective case comparison study of the relationship between an Integrated Care Pathway for people diagnosed with schizophrenia in acute mental health care and service users' length of stay, readmission rates and follow-up within 7 days of discharge. J Psychiatr Ment Health Nurs 2017; 24:348-357. [PMID: 28296070 DOI: 10.1111/jpm.12386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2017] [Indexed: 11/30/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: There is some evidence reporting the value of diagnostic-driven Integrated Care Pathways (ICPs) in reducing service users' length of inpatient stay, readmission rates and follow-up within seven days of discharge, but this evidence is untested in studies comparing care using ICP with other forms of care planning. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: This study present findings from research comparing care in a Trust that uses an ICP with a Trust using another form of care planning to direct the care of people diagnosed with schizophrenia. We were interested particularly in whether using an ICP was linked to length of inpatient stay, readmission rates and follow-up care within seven days of discharge. The results compare ICP driven care with another form of care. This study adds to the international evidence by being among the first to compare empirically, outcomes in a mental health Trust using an ICP with a Trust not using an ICP to direct care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses are central to the delivery of the psychosocial aspects of ICPs in particular and judging by the link between psychosocial interventions and quality of mental health care, it is possible that nurse-led psychosocial interventions contributed to the reduced length of stay. ABSTRACT Background Integrated Care Pathways (ICPs) are used to deliver mental health services, yet evidence relating to outcomes is mixed. Aim To compare service users' length of stay, readmission rates and follow-up within 7 days of discharge in a mental health Trust using an ICP to direct the care of people diagnosed with schizophrenia with a Trust using a nonICP method of care planning in England. METHOD A cohort study with a random sample of 400 service users with outcomes analysed retrospectively. Results The ICP Trust had a 13.5 day shorter average length of stay, this difference was statistically significant. No statistically significant differences were observed in rates of readmission or follow-up within 7 days of discharge. Discussion and implications Mental health nurses are central to the delivery of the psychosocial aspects of ICPs in particular and judging by the link between psychosocial interventions and quality of mental health care, it is possible that nurse-led psychosocial interventions contributed to the reduced length of stay.
Collapse
Affiliation(s)
- J Attfield
- Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - S Brown
- Institute of Mental Health, Nottingham, UK
| | - T Carter
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - P Callaghan
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK
| |
Collapse
|
8
|
Impact of an Alcohol Withdrawal Treatment Pathway on Hospital Length of Stay: A Retrospective Observational Study Comparing Pre and Post Pathway Implementation. J Psychiatr Pract 2017; 23:233-241. [PMID: 28492463 DOI: 10.1097/pra.0000000000000229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine if the implementation of a hospital-specific alcohol withdrawal treatment pathway used in a medical-surgical patient population decreased hospital length of stay (LOS) compared with the standard of care. METHODS This retrospective observational study, conducted in a large academic tertiary care hospital, involved 582 subjects who met criteria for study inclusion, with 275 subjects in the 2010 cohort and 307 in the 2012 cohort. The Alcohol Withdrawal Project Team was formed with the goal of creating a standardized approach to the recognition and treatment of alcohol withdrawal at Duke University Hospital. The group created a computerized physician order entry alcohol withdrawal treatment pathway with 4 possible treatment paths chosen on the basis of current withdrawal symptoms, vital signs, and alcohol withdrawal history. The 4 treatment paths are 1 prophylaxis; 2 mild-to-moderate withdrawal; 3 moderate-to-severe withdrawal, and 4 severe withdrawal/alcohol withdrawal delirium. Each treatment path corresponds to a different lorazepam dose and dose schedule and symptom assessment. This pathway was implemented in the hospital at the end of 2011. RESULTS Using a Cox proportional hazards model and adjusting for covariates, there was a 1 day [95% confidence interval (CI), 1-2 d] reduction in median hospital LOS between the 2010 and 2012 cohorts, 5 versus 4 days, respectively. The average ratio in hospital LOS between the 2 cohorts was 1.25 (95% CI, 1.25-1.67). The CI was estimated by bootstrapping and indicated a significantly longer LOS in the 2010 cohort compared with the 2012 cohort. Nonsignificant changes were found in the proportion of subjects admitted to the intensive care unit (24% in 2010 vs. 29.3% in 2012), LOS in the intensive care unit (7.1±8 d in 2010 vs. 5.6±6.9 d in 2012), and proportion of patients discharged with a diagnosis of delirium tremens (17.8% in 2010 vs. 15.3% in 2012). CONCLUSIONS This study demonstrates the successful implementation of an alcohol withdrawal treatment pathway in a medical-surgical population hospitalized in a large tertiary care facility with significant impact on hospital LOS.
Collapse
|
9
|
|
10
|
Melson J, Kane M, Mooney R, Mcwilliams J, Horton T. Improving alcohol withdrawal outcomes in acute care. Perm J 2014; 18:e141-5. [PMID: 24867561 DOI: 10.7812/tpp/13-099] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Excessive alcohol consumption is the nation's third leading cause of preventable deaths. If untreated, 6% of alcohol-dependent patients experience alcohol withdrawal, with up to 10% of those experiencing delirium tremens (DT), when they stop drinking. Without routine screening, patients often experience DT without warning. OBJECTIVE Reduce the incidence of alcohol withdrawal advancing to DT, restraint use, and transfers to the intensive care unit (ICU) in patients with DT. DESIGN In October 2009, the alcohol withdrawal team instituted a care management guideline used by all disciplines, which included tools for screening, assessment, and symptom management. Data were obtained from existing datasets for three quarters before and four quarters after implementation. Follow-up data were analyzed and showed a great deal of variability in transfers to the ICU and restraint use. Percentage of patients who developed DT showed a downward trend. MAIN OUTCOME MEASURES Incidence of alcohol withdrawal advancing to DT and, in patients with DT, restraint use and transfers to the ICU. RESULTS Initial data revealed a decrease in percentage of patients with alcohol withdrawal who experienced DT (16.4%-12.9%). In patients with DT, restraint use decreased (60.4%-44.4%) and transfers to the ICU decreased (21.6%-15%). Follow-up data indicated a continued downward trend in patients with DT. Changes were not statistically significant. Restraint use and ICU transfers maintained postimplementation levels initially but returned to preimplementation levels by third quarter 2012. CONCLUSION Early identification of patients for potential alcohol withdrawal followed by a standardized treatment protocol using symptom-triggered dosing improved alcohol withdrawal management and outcomes.
Collapse
Affiliation(s)
- Jo Melson
- Nurse Practitioner in the Stepdown Unit at Christiana Care Health System in Wilmington, DE.
| | - Michelle Kane
- Medicine Outcomes Coordinator in the Performance Improvement Department at Christiana Care Health System in Newark, DE.
| | - Ruth Mooney
- Research Facilitator for the Christiana Care Health System in Newark, DE.
| | - James Mcwilliams
- Nurse Practitioner with the Healthstar Physicians of Hot Springs, AR.
| | - Terry Horton
- Chief of the Division of Addiction Medicine for the Christiana Care Health System in Newark, DE.
| |
Collapse
|
11
|
Maldonado JR, Sher Y, Ashouri JF, Hills-Evans K, Swendsen H, Lolak S, Miller AC. 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. Alcohol 2014; 48:375-90. [PMID: 24657098 DOI: 10.1016/j.alcohol.2014.01.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Revised: 01/22/2014] [Accepted: 01/23/2014] [Indexed: 01/10/2023]
Abstract
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.
Collapse
Affiliation(s)
- José R Maldonado
- Psychiatry, Internal Medicine, Surgery, & Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Yelizaveta Sher
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Judith F Ashouri
- Internal Medicine (Rheumatology), University of California, San Francisco, CA, USA
| | | | - Heavenly Swendsen
- Psychosomatic Medicine, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Sermsak Lolak
- Psychiatry, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | | |
Collapse
|
12
|
Abstract
In acute hospital settings, alcohol withdrawal often causes significant management problems and complicates a wide variety of concurrent conditions, placing a huge burden on the NHS. A significant number of critical incidents around patients who were undergoing detoxification in a general hospital setting led to the need for a project to implement and evaluate an evidence-based approach to the management of alcohol detoxification-a project that included a pre-intervention case note audit, the implementation of an evidence-based symptom-triggered detoxification protocol, and a post-intervention case note audit. This change in practice resulted in an average reduction of almost 60% in length of hospital stay and a 66% reduction in the amount of chlordiazepoxide used in detoxification, as well as highlighting that 10% of the sample group did not display any signs of withdrawal and did not require any medication. Even with these reductions, no patient post-intervention developed any severe signs of withdrawal phenomena, such as seizures or delirium tremens. The savings to the trust (The Pennine Acute Hospital Trust) are obvious,but the development of a consistent, quality service will lead to fewer long-term negative effects for patients that can be caused by detoxification. This work is a project evaluation of a locally implemented strategy, which, it was hypothesised,would improve care by providing an individualised treatment plan for the management of alcohol withdrawal symptoms.
Collapse
|
13
|
Fullwood JE, Mostaghimi Z, Granger CB, Washam JB, Bride W, Zhao Y, Granger BB. Alcohol withdrawal prevention: a randomized evaluation of lorazepam and ethanol--a pilot study. Am J Crit Care 2013; 22:398-406. [PMID: 23996419 DOI: 10.4037/ajcc2013283] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Alcohol withdrawal syndrome, characterized by confusion, agitation, and hallucinations, decreases the safety of patients with acute myocardial infarction. Unexpected hospitalization and sudden cessation of alcohol consumption may increase in-hospital complications and length of stay and even precipitate death. PURPOSE To perform a randomized evaluation of lorazepam and ethanol/lorazepam to evaluate the safety and efficacy of these 2 strategies for preventing alcohol withdrawal syndrome in patients with acute coronary syndromes. METHODS Patients (n = 57) with myocardial infarction were screened for alcohol dependence by using the CAGE questionnaire and randomized to treatment with lorazepam or ethanol with lorazepam. Demographics and complication rates were analyzed by using χ² tests (categorical variables) and t tests (continuous variables). Safety (composite complication rates) of the treatment strategy was evaluated by using the Fisher exact test, and length of stay by using the Wilcoxon rank-sum test. RESULTS Safety-associated complication rates (self-extubation, delirium tremens, reinfarction) did not differ between groups (24% lorazepam vs 18% ethanol; P = .56). Days spent in the cardiac intensive care unit (7% lorazepam vs 2% ethanol; P = .32) and overall hospital stay (6% lorazepam vs 6% ethanol; P = .72) did not differ between the 2 groups. CONCLUSIONS These preliminary findings suggest that a randomized evaluation of treatment strategies to prevent complications associated with alcohol withdrawal in patients with acute myocardial infarction is safe and feasible.
Collapse
Affiliation(s)
- Joyce E Fullwood
- Cardiac Intensive Care Unit, Duke University Hospital, Durham, NC, USA
| | | | | | | | | | | | | |
Collapse
|
14
|
|
15
|
Barros REM, Tung TC, Mari JDJ. [Psychiatric emergency services and their relationships with mental health network in Brazil]. BRAZILIAN JOURNAL OF PSYCHIATRY 2011; 32 Suppl 2:S71-7. [PMID: 21140074 DOI: 10.1590/s1516-44462010000600003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review the literature concerning the role and the inclusion of emergency psychiatric services in mental health networks. METHOD We performed a search in online databases (PubMed and SciELO) of empirical articles and reviews about emergency psychiatric services and networks of mental health services. RESULTS Emergency psychiatric services are a core unit for a proper functioning of mental health networks, by both the management of emergencies itself, and the regulation of the network where it belongs. The emergency psychiatric services relate to all inpatient and outpatient services, allowing the organization of the flow of admissions and avoiding the overload of the network of mental health.The functions of emergency psychiatric services are broad and go beyond the simple referral for hospitalization, since clinical stabilization and psychosocial support can be reached in well structured emergency psychiatric services. In Brazil, these functions were expanded after the mental health reform and the burden of mental health network caused by difficulties and limitations of inpatient and outpatient services. CONCLUSION Emergency psychiatric services should be recovered and expanded; especially those located in general hospitals. It is suggested that investment in psychiatric emergencies should be a priority of the Brazilian public health policies for improving the mental health care.
Collapse
Affiliation(s)
- Régis Eric Maia Barros
- Divisão de Psiquiatria, Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | | | | |
Collapse
|
16
|
Finn KM, Greenwald J. Hospitalists and alcohol withdrawal: yes, give benzodiazepines but is that the whole story? J Hosp Med 2011; 6:435-7. [PMID: 21990171 DOI: 10.1002/jhm.966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
17
|
Refeeding Syndrome as an Iatrogenic Cause of Delirium: A Retrospective Pilot Study. PSYCHOSOMATICS 2010. [DOI: 10.1016/s0033-3182(10)70724-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
18
|
Riddle E, Bush J, Tittle M, Dilkhush D. Alcohol withdrawal: development of a standing order set. Crit Care Nurse 2010; 30:38-47; quiz 48. [PMID: 20194571 DOI: 10.4037/ccn2010862] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Evanthia Riddle
- Bayfront Medical Center, 701 Sixth Street South, St Petersburg, FL 33701, USA.
| | | | | | | |
Collapse
|
19
|
Stern TA, Gross AF, Stern TW, Nejad SH, Maldonado JR. Current approaches to the recognition and treatment of alcohol withdrawal and delirium tremens: "old wine in new bottles" or "new wine in old bottles". PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2010; 12:PCC.10r00991. [PMID: 20944765 PMCID: PMC2947546 DOI: 10.4088/pcc.10r00991ecr] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
20
|
Murphy MK, Chabon B, Delgado A, Newville H, Nicolson SE. Development of a substance abuse consultation and referral service in an academic medical center: challenges, achievements and dissemination. J Clin Psychol Med Settings 2009; 16:77-86. [PMID: 19219627 DOI: 10.1007/s10880-009-9149-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 01/20/2009] [Indexed: 11/26/2022]
Abstract
Approximately 25% of US hospital beds are occupied by individuals with active substance use disorders (SUD). Acute medical hospitalization provides an opportunity to address SUDs and provide patient-centered intervention and referral for treatment. Nationally, some hospitals have developed substance abuse consultation departments to improve the care of hospitalized substance users. In this paper we describe the Addiction Psychiatry Service (APS) in a large urban hospital which provides bed-side SUD consultation, screening, intervention and referral to treatment. APS utilizes the multiple disciplines of psychology, social work and medicine to integrate substance abuse services throughout the hospital and educate future generations of medical and psychology trainees. We conclude with how the APS service is informing the development of similar programs in other academic departments within our hospital and best practice recommendations to further disseminate this service model.
Collapse
Affiliation(s)
- Mary K Murphy
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
| | | | | | | | | |
Collapse
|