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

2. Background The number of dependant drinkers in England stands at 1.6 million The number of dependant drinkers in England stands at 1.6 million The cost to the NHS is £2.7 Billion every year and is set to rise to £3.7 Billion The cost to the NHS is £2.7 Billion every year and is set to rise to £3.7 Billion Alcohol withdrawal often causes significant management problems and complicates the management of a wide variety of concurrent conditions Alcohol withdrawal often causes significant management problems and complicates the management of a wide variety of concurrent conditions The number of hospital admissions was 1.1 million in 2009/2010, a 100% increase since 2002/03. The number of hospital admissions was 1.1 million in 2009/2010, a 100% increase since 2002/03.

3. Background Continued Although alcohol use and abuse are common among inpatients, many patients are inadequately assessed and treated for alcohol withdrawal Although alcohol use and abuse are common among inpatients, many patients are inadequately assessed and treated for alcohol withdrawal Excessive drinking is currently the second greatest risk to public health in developed countries Excessive drinking is currently the second greatest risk to public health in developed countries Although most of that risk is avoidable the risk is clearly apparent with the large number of hospital admissions every year Although most of that risk is avoidable the risk is clearly apparent with the large number of hospital admissions every year

4. The Project Is commissioned as part of Manchester’s Alcohol Strategy Is commissioned as part of Manchester’s Alcohol Strategy IBA work with harmful and hazardous drinkers IBA work with harmful and hazardous drinkers Work with dependant drinkers Work with dependant drinkers Reducing attendance rate of ‘frequent fliers’ Reducing attendance rate of ‘frequent fliers’ Alcohol Withdrawal Policy Alcohol Withdrawal Policy

5. Part 1 Aims Pre intervention audit Pre intervention audit Identify current practice Identify current practice Identify any short falls Identify any short falls Compare current practice to national guidance Compare current practice to national guidance Identify a need for change in practice Identify a need for change in practice

6. Part 2 Aims Intervention stage Intervention stage Implementation of an Integrated Care Pathway (ICP) Implementation of an Integrated Care Pathway (ICP) Incorporating Assessment tool (CIWA score) Incorporating Assessment tool (CIWA score) Management pathways Management pathways Standardise management of alcohol withdrawal Standardise management of alcohol withdrawal Implementation of a symptom-triggered approach to care Implementation of a symptom-triggered approach to care

7. Part 3 Aims Post intervention audit- Complete audit cycle Post intervention audit- Complete audit cycle Has the intervention been successful? Has the intervention been 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 audits Compare findings from both audits

8. Audit 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 met Important 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 improvement How much Chlordiazepoxide was administered? How much Chlordiazepoxide was administered? Important 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 further 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 assessment 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 group Is there consistency with prescribing? Is there consistency with prescribing? This will identify any problems with medical prescribing. Are the medicines prescribed in proper place? Are all areas of Kardex complete? Did anyone develop delirium or seizure activity following commencement on a detox? Did anyone develop delirium or seizure activity following commencement on a detox? This will help identify differences between symptom-triggered management and predetermined dosing.

9. Sample Groups Both groups contained fifty patients Both groups contained fifty patients Convenience sample Convenience sample All patients completed a detox in hospital All patients completed a detox in hospital All patients were alcohol dependent within DSMV-IV and ICD 10 classifications All patients were alcohol dependent within DSMV-IV and ICD 10 classifications

10. Discussion

11. Pre ICP implementation Practice No consistency with prescribing No consistency with prescribing No official guidelines No official guidelines Prophylactic dosing regimes Prophylactic dosing regimes Medication not individually tailored to patient Medication not individually tailored to patient Non-licensed medication being used Non-licensed medication being used No assessment scoring to measure withdrawal severity No assessment scoring to measure withdrawal severity

12. Clinical Incidents As a background Clinical incidents involving alcohol were investigated As a background Clinical incidents involving alcohol were investigated Coroners court Coroners court Identified a need for change Identified a need for change Multiple incidents involving alcohol Multiple incidents involving alcohol

13. No of days to complete a detox Pre change average number of days to complete audit was 6.36 days Pre change average number of days to complete audit was 6.36 days Post change average number of days to complete audit was 2.48 days Post change average number of days to complete audit was 2.48 days

14. How much Chlordiazepoxide was administered? Pre implemenation-Average number of milligrams to complete an inpatient detox was 563.3 mg. Pre implemenation-Average number of milligrams to complete an inpatient detox was 563.3 mg. 40% were given PRN medication but in only 10% of these (2 cases) was the reason for this documented 40% were given PRN medication but in only 10% of these (2 cases) was the reason for this documented Six of the prescriptions did not use Chlordiazepoxide but used other medication. Six of the prescriptions did not use Chlordiazepoxide but used other medication. Post implementation- Average number of milligrams of Chlordiazepoxide to complete an inpatient detox was 167.2 mg. Post implementation- Average number of milligrams of Chlordiazepoxide to complete an inpatient detox was 167.2 mg. Chlordiazepoxide was the only drug used Chlordiazepoxide was the only drug used 5 patients required no Chlordiazepoxide 5 patients required no Chlordiazepoxide

15. Consistency With Prescribing Pre Intervention No uniformity No uniformity Differing regimes used Differing regimes used Multiple prescribing errors noted Multiple prescribing errors noted Administration errors noted Administration errors noted Post Intervention All patients prescribed the same medication All patients prescribed the same medication All prescribed appropriately All prescribed appropriately All used symptom- triggered approach to care All used symptom- triggered approach to care Some administration errors still Some administration errors still

16. Development of further withdrawal phenomena 14 patients in the pre-intervention group developed severe signs of withdrawal following commencement on a detox 14 patients in the pre-intervention group developed severe signs of withdrawal following commencement on a detox Compared to 3 patients in the post- intervention group Compared to 3 patients in the post- intervention group

17. Staff Satisfaction A questionnaire was utilised using open and closed questions A questionnaire was utilised using open and closed questions Was sent to 200 staff Was sent to 200 staff 138 were returned 138 were returned Staff satisfaction was noted to improve Staff satisfaction was noted to improve Staff had noted improvement in patient care Staff had noted improvement in patient care Documentation Documentation Time management Time management Confidence Confidence

18. Documentation There are clear improvements in documentation There are clear improvements in documentation This was needed as highlighted from Coroners Court and other clinical incidents This was needed as highlighted from Coroners Court and other clinical incidents All clinicians now documenting withdrawal symptoms in same document All clinicians now documenting withdrawal symptoms in same document User friendly document allowing clinical staff to score the symptoms therefore all clinicians involved with patient can identify what signs and symptoms the patient has been portraying User friendly document allowing clinical staff to score the symptoms therefore all clinicians involved with patient can identify what signs and symptoms the patient has been portraying Much easier to rule out Wernicke’s encephalopathy or Anxiety related disorders being mismanaged with Chlordiazepoxide. Much easier to rule out Wernicke’s encephalopathy or Anxiety related disorders being mismanaged with Chlordiazepoxide.

19. Costing The average cost of an inpatient stay is £300 per night The average cost of an inpatient stay is £300 per night The average cost to complete an inpatient detox before symptom-triggered approach to care was £1,908. The average cost to complete an inpatient detox before symptom-triggered approach to care was £1,908. Compares to £744 for post intervention group. Compares to £744 for post intervention group. Further costing reductions could be noteed in pharmacy costs. Further costing reductions could be noteed in pharmacy costs. The printing costs for 3000 booklets/ICP’s is £1191.72 The printing costs for 3000 booklets/ICP’s is £1191.72

20. Costing

21. Mann-Whitney Test Mann-Whitney parametric test used Mann-Whitney parametric test used P-value is 0.0001 P-value is 0.0001

22. Conclusions A symptom-triggered approach is appropriate in the management of alcohol withdrawal A symptom-triggered approach is appropriate in the management of alcohol withdrawal Improves care Improves care Improves treatment duration Improves treatment duration Decrease in medication required Decrease in medication required Harmonised clinical management Harmonised clinical management Improved documentation Improved documentation Staff satisfaction noted Staff satisfaction noted Significant Costing differences Significant Costing differences

23. References Alcohol Concern (2010) Investing in Alcohol Treatments: Reducing Costs and Saving. Alcohol Concern. London. Alcohol Concern (2010) Investing in Alcohol Treatments: Reducing Costs and Saving. Alcohol Concern. London. Alcohol Concern (2011) Making Alcohol a Health Priority- Opportunities to Reduce alcohol Harms and Rising Costs. Alcohol Concern. London. Alcohol Concern (2011) Making Alcohol a Health Priority- Opportunities to Reduce alcohol Harms and Rising Costs. Alcohol Concern. London. Foy A., Kay J., and Taylor A. (2002) The course of alcohol withdrawal in a general hospital. QJM Vol 90 pp. 253-261. Foy A., Kay J., and Taylor A. (2002) The course of alcohol withdrawal in a general hospital. QJM Vol 90 pp. 253-261. Kaner E. (2010) Brief interventions against excessive alcohol consumption. In: Oxford Textbook of Medicine. Oxford University Press, Oxford, pp. 1334-1336 Kaner E. (2010) Brief interventions against excessive alcohol consumption. In: Oxford Textbook of Medicine. Oxford University Press, Oxford, pp. 1334-1336 NICE (2010) Alcohol Use Disorders: Diagnosis and clinical management of alcohol related physical complications. London. National Institute for Health and Clinical Excellence. NICE (2010) Alcohol Use Disorders: Diagnosis and clinical management of alcohol related physical complications. London. National Institute for Health and Clinical Excellence. NICE (2010b) Alcohol Use Disorders: Sample Chlordiazepoxide dosing regimens for use in managing alcohol withdrawal. London. National Institute for Health and Clinical Excellence NICE (2010b) Alcohol Use Disorders: Sample Chlordiazepoxide dosing regimens for use in managing alcohol withdrawal. London. National Institute for Health and Clinical Excellence Repper-Delisi J., Stern T.A., Mitchell M., Lussier-cushing M, Lakatose B.,Frichione G. et al. (2008) Successful Implementation of an Alcohol- Withdrawal Pathway in a General Hospital. Psychosomatics Vol 49(4) pp. 292-299. Repper-Delisi J., Stern T.A., Mitchell M., Lussier-cushing M, Lakatose B.,Frichione G. et al. (2008) Successful Implementation of an Alcohol- Withdrawal Pathway in a General Hospital. Psychosomatics Vol 49(4) pp. 292-299. 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 Department. Drug and Alcohol Dependence Vol 77 pp. 205-208. 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 Department. Drug and Alcohol Dependence Vol 77 pp. 205-208.