Disclosures. Learning Objective 4/26/2017

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1 Management of acute alcohol withdrawal at a community hospital in an area with a high prevalence of alcoholism { Melissa Cirillo, Pharm.D. 4/29/2017 Financial: None Nonfinancial: None Disclosures List the most common benzodiazepines used for symptom management of alcohol withdrawal Learning Objective 1

2 Bozeman Health Deaconess Hospital Bozeman Health { Deaconess Hospital { 86 bed facility Level III trauma center Employs 200 physicians and healthcare professionals Over 35 specialties Bozeman Health System Additional facilities Bozeman Health Big Sky Medical Center Critical access care to Big Sky and West Yellowstone Bozeman Health Medical Group Primary care, specialty physicians Bozeman Health Urgent Care Bozeman Health Hillcrest Senior Living Offers housing to over 150 seniors Bozeman Health Foundation Manages all donations to generate financial support for Bozeman Health needs Alcohol is the fourth leading preventable cause of death in the United States 31% of driving fatalities In 2013, it was estimated that 46% of all liver disease deaths directly involved alcohol According to the Centers for Disease Control and Prevention, the prevalence of binge drinking in Montana in 2015 was approximately 25% In 2014, Montana had the second highest rate of alcohol-related deaths in the country Background 2

3 Acute alcohol withdrawal syndrome is diagnosed based on evidence of recent discontinuation or decrease in alcohol intake in combination with clear signs and symptoms of withdrawal Anxiety Nausea Tachycardia Seizure or delirium tremens (DT) Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale: gold standard for symptom severity assessment Benzodiazepines remain the staple for symptom management Long-acting formulations have been proven to reduce the risk of seizure and DT Diazepam, chlordiazepoxide Short-acting formulations may be more appropriate in patients with liver disease, in whom longer-acting benzodiazepines may accumulate Lorazepam, oxazepam Background Fixed-dose and symptom-triggered benzodiazepine regimens have both been used successfully Symptom-triggered therapy Less medication Shorter duration of stay in the hospital Refractory withdrawal Phenobarbital has been shown to be as effective as benzodiazepines Decreases intensive care unit (ICU) length of stay Single dose + symptom-triggered benzodiazepine therapy Propofol Dexmedetomidine Background Evaluate BHDH s alcohol withdrawal management processes and protocols in comparison to current treatment guidelines Evaluate adherence to the protocols Determine if interventions made for identified treatment gaps result in fewer hospital admissions to the ICU Objectives 3

4 Phase I: retrospective review Sanford Health Clarity Report January June, 2016 Patients > 16 years of age with admission diagnosis of alcohol withdrawal syndrome Age, gender, hospital admission areas (emergency department (ED), medical floor, surgical floor, ICU), initial blood alcohol content (BAC), CIWA-Ar scores (dates, times), benzodiazepine administration (medication, dose, date, time) Methods: Phase I Phase II: interventions Updated ED alcohol withdrawal protocol and order set Symptom-triggered therapy based on CIWA-Ar score Phenobarbital for severe/refractory withdrawal Conducted ED nursing education regarding appropriate assessment and care of patients in alcohol withdrawal CIWA-Ar administration Medication adverse effect monitoring Phase II: retrospective review, March April, 2017 Same criteria as Phase I Methods: Phase II { Phase I (6 months) { Phase II (1 month) Results 4

5 { Phase I (6 months) { Phase II (1 month) Results n = 10 n = 4 n = 0 Phase I Results Phase II Results 5

6 n = 2 n = 3 Phase I Results Phase II Results Areas improved Hospital length of stay: 6.6 days to 2.1 days ICU admissions: 30% to 8.3 % Direct ED to ICU admissions: 20% to 0% Patients in the ED with no documented CIWA-Ar score: 52% to 16.7% Patients who received no medication for symptom management in the ED: 40% to 0% Areas in need of improvement Still not measuring BAC in each patient Important to rule out other diagnoses and direct therapy Order set build is still in process Limitations Phase II results are based on a limited amount of data (one month, 12 patients) Discussion 6

7 Phase I results of this study identified gaps in BHDH s processes for assessing and treating patients in acute alcohol withdrawal. Nursing education and protocol updates improved the rate of symptom severity assessment and treatment in the ED and decreased hospital length of stay and ICU admissions. Conclusions References 1. Alcohol Facts and Statistics. National Institute on Alcohol Abuse and Alcoholism. Updated January Available at: 2. Behavioral Risk Factor Surveillance System: Prevalence of Binge Drinking Among Adults, Alcohol and Public Health. Centers for Disease Control and Prevention. Updated September Available at: 3. Alcohol: Death rate per 100,000. USA Life Expectancy. CDC Official Final Deaths Available at: 4. Kattimani S, Bharadway B. Clinical management of alcohol withdrawal: A systematic review. Ind Psychiatry J 2013;22(2): Bayard M, McIntyre J, Hill K, Woodside J Jr. Alcohol withdrawal syndrome. Am Fam Physician 2004;69(6): Burns M, Price J, Lekawa M. Delirium tremens (Dts) clinical presentation. Updated April 14, Available at: 7. Management of alcohol withdrawal. World Health Organization Accessed September 6, Available at: 8. Mirijello A, D Angelo C, Ferrulli A, Vasallo G, Antonelli M, Caputo F, Leggio L, Gasbarrini A, Addolorato G. Identification and management of alcohol withdrawal syndrome. Drugs 2015;75: Gold J, Rimal B, Nolan A, Nelson L. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med 2007;35(3): Hendley G, Dery R, Barnes R, Snowden B, Mentler P. A prospective, randomized trial of phenobarbital versus benzodiazepines for acute alcohol withdrawal. Am J Emerg Med 2011;29: Michaelsen I, Anderson J, Fink-Jensen A, Allerup P, Ulrichsen J. Phenobarbital versus diazepam for delirium tremens- a retrospective study. Dan Med Bul 2010;57(8): Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: A prospective, randomized, double-blind, placebo-controlled study. J Emerg Med 2013;44(3): Melissa Cirillo mcirillo@bozemanhealth.org Contact Information 7