Alcohol withdrawal: development of a standing order set

Risk Factors for Severe Alcohol Withdrawal Syndrome in an Acute Hospital Population

BACKGROUND

The literature lacks consensus to the factors that increase the risk of a patient developing severe alcohol withdrawal syndrome (SAWS).

AIM

The study set out to identify the variables that increase the risk of SAWS in patients who have alcohol dependence syndrome.

METHODS

A case-control study was designed to investigate the variables associated with SAWS in an acute hospital setting. Three hundred eighty-two case and 382 control patients were randomly selected retrospectively from referrals to the acute addiction liaison nursing service during a 12-month period (January 1, 2015, to December 31, 2015). Statistical significance (p < .05) and association with SAWS were calculated using chi-square, Cramer's V test, odds ratio, and Levene's test.

RESULTS

Twenty-four variables have been identified as associated with SAWS development. Five of the 24 variables had a moderate-to-strong association with SAWS risk: Fast Alcohol Screening Test, Glasgow Modified Alcohol Withdrawal Scale score, AWS admission, hours since the last drink, and systolic blood pressure. The study also identified that comorbidity was associated with not developing SAWS.

CONCLUSION/RECOMMENDATIONS

These findings confirm that noninvasive variables collected in the emergency department are useful in identifying a person's risk of developing SAWS. The results of this study are a useful starting point in the exploration of SAWS and the development of a tool for use in the emergency department that can stratify risk into high and low and is the next stage of this program of work.

Implementing an Alcohol Withdrawal Protocol: A Quality Improvement Project

This quality improvement project evaluates the effectiveness of implementing an evidence-based alcohol withdrawal protocol in an acute care setting. Patient outcomes, length of stay, and nurses' knowledge and satisfaction with care are compared pre- and postimplementation. Implementation resulted in significant reduction of restraint use, transfers to critical care, 1:1 observation, and length of stay, whereas no reduction was seen in rapid response calls. Nurses' knowledge post-alcohol withdrawal protocol education increased and satisfaction with patient care improved.

The role of alcohol as men desist from physical intimate partner violence

INTRODUCTION AND AIMS

Although researchers have examined the relationship between alcohol and perpetration of intimate partner violence (IPV), little research has examined the role of alcohol within the process of desistance from IPV, which was the aim of this study.

DESIGN AND METHODS

A mixed-methods approach was taken as both psychometric test and interview data were analysed. Scores on the Millon Clinical Multiaxial Inventory III alcohol dependence subscale of 37 men deemed to have desisted from IPV, 50 deemed to be persisting with IPV and 49 non-violent controls were compared. In addition, data about alcohol use from interviews with 13 desisters, 9 persisters, 9 IPV intervention facilitators and 7 female survivors were analysed using thematic analysis to understand the role of alcohol in IPV desistance and persistence.

RESULTS

No differences were found between the groups' self-reported alcohol dependence based on their Millon Clinical Multiaxial Inventory III scores. However, analysis of the interview data revealed that compared with persisters, desisters reported having changed their attitudes towards alcohol and their consumption of it in order to facilitate their cessation of violence.

DISCUSSION AND CONCLUSIONS

Static measures of alcohol dependence need to be used with caution if looking to identify progress with desistance from IPV. For individuals for whom alcohol played a role in their IPV, changing attitudes and their use of alcohol were described as being important in the process of desistance. Self-reported attitudes and alcohol use could therefore be used to identify men who are making progress in the process of desistance from IPV. [Walker K. The role of alcohol as men desist from physical intimate partner violence. Drug Alcohol Rev 2017;36:134-142].

Reducing physical restraint use in alcohol withdrawal patients: a literature review

Alcohol withdrawal patients experience symptoms ranging from mild anxiety and disorientation to severe agitation and hallucinations. The most critical of these patients are treated in intensive care units. Physical restraints are often required to maintain patient safety until symptoms resolve. The use of physical restraints is contradictory to nursing values and is unsupported by evidenced-based literature. A literature review was conducted to see what, if any, alternatives have been tested to improve patient care for this complicated patient population.

Assessment of affective and somatic signs of ethanol withdrawal in C57BL/6J mice using a short-term ethanol treatment

Alcohol is one of the most prevalent addictive substances in the world. Withdrawal symptoms result from abrupt cessation of alcohol consumption in habitual drinkers. The emergence of both affective and physical symptoms produces a state that promotes relapse. Mice provide a preclinical model that could be used to study alcohol dependence and withdrawal while controlling for both genetic and environmental variables. The use of a liquid ethanol diet offers a reliable method for the induction of alcohol dependence in mice, but this approach is impractical when conducting high-throughput pharmacological screens or when comparing multiple strains of genetically engineered mice. The goal of this study was to compare withdrawal-associated behaviors in mice chronically treated with a liquid ethanol diet vs. mice treated with a short-term ethanol treatment that consisted of daily ethanol injections containing the alcohol dehydrogenase inhibitor, 4-methylpyrazole. Twenty-four hours after ethanol treatment, mice were tested in the open field arena, the elevated plus maze, the marble burying test, or for changes in somatic signs during spontaneous ethanol withdrawal. Anxiety-like and compulsive-like behaviors, as well as physical signs, were all significantly elevated in mice undergoing withdrawal, regardless of the route of ethanol administration. Therefore, a short-term ethanol treatment can be utilized as a screening tool for testing genetic and pharmacological agents before investing in a more time-consuming ethanol treatment.

Using an 'action set' for the management of acute upper gastrointestinal bleeding

BACKGROUND

We studied the management of patients with acute upper gastrointestinal (GI) bleeding (AUGIB) at the Royal Free Hospital. The aim was to compare our performance with the national standard and determine ways of improving the delivery of care in accordance with the recently published 'Scope for improvement' report.

METHODS

We randomly selected patients who presented with haematemesis, melaena, or both, and had an oesophageogastroduodenoscopy (OGD) between April and October 2009. We developed local guidelines and presented our findings in various forums. We collaborated with the British Medical Journal's Evidence Centre and Cerner Millennium electronic patient record system to create an electronic 'Action Set' for the management of patients presenting with AUGIB. We re-audited using the same standard and target.

RESULTS

With the action set, documentation of pre-OGD Rockall scores increased significantly (p ≤ 0.0001). The differences in the calculation and documentation of post-OGD full Rockall scores were also significant between the two audit loops (p = 0.007). Patients who inappropriately received proton-pump inhibitors (PPIs) before endoscopy were reduced from 73.8% to 33% (p = 0.02). Patients receiving PPIs after OGD were also reduced from 66% to 50% (p = 0.01). Discharges of patients whose full Rockall score was less than or equal to two increased from 40% to 100% (p = 0.43).

CONCLUSION

The use of the Action Set improved calculation and documentation of risk scores and facilitated earlier hospital discharge for low-risk patients. Significant improvements were also seen in inappropriate use of PPIs. Actions sets can improve guideline adherence and can potentially promote cost-cutting and improve health economics.

Alcohol withdrawal

Alcohol withdrawal is a common clinical condition that has a variety of complications and morbidities. The manifestations can range from mild agitation to withdrawal seizures and delirium tremens. The treatments for alcohol withdrawal include benzodiazepines, anticonvulsants, beta-blockers and antihypertensives. Although benzodiazepines are presently a first-line therapy, there is controversy regarding the efficacies of these medications compared with others. Treatment protocols often involve one of two contrasting approaches: symptom-triggered versus fixed-schedule dosing of benzodiazepines. We describe these protocols in our review and examine the data supporting symptom-triggered dosing as the preferred method for most patients in withdrawal.The Clinical Institute Withdrawal Assessment for Alcohol scoring system for alcohol withdrawal streamlines care, optimizes patient management, and is the best scale available for withdrawal assessment. Quality improvement implications for inpatient management of alcohol withdrawal include increasing training for signs of withdrawal and symptom recognition, adding new hospital protocols to employee curricula, and ensuring manageable patient-to-physician and patient-to-nurse ratios.