Introduction Around 12% of emergency department attendances are directly related to alcohol, with associated cost to the NHS. Historically, fixed-rate chlordiazepoxide regimens have been used for alcohol withdrawal, but recent trials have suggested that symptom-triggered regimens may be more cost-effective, and reduce length-of-stay without adverse effect. We aimed to evaluate the efficacy and safety of introducing a symptom-guided regimen to a district general hospital (DGH) Acute Assessment Unit (AAU).
Method Data were collected prospectively for consecutive admissions requiring alcohol withdrawal in 2-month periods before and after training to reinforce the symptom-guided regimen. During a 2-week intervention period after the initial 2-month data collection, training on the symptom-guided protocol was delivered to the AAU nursing staff by the alcohol liaison nurse and ongoing support to clinicians was given by the alcohol liaison team. CIWA(Ar) protocols were made available on the intranet and in paper form on the ward. The primary outcome measure was length of stay (days), with secondary outcome measures including adverse events and milligrams of chlordiazepoxide (or equivalent benzodiazapine) given in first 24 h. We also surveyed the nursing staff on ease of implementation of the regimen.
Results Pre-intervention group: 20 patients identified as at risk of withdrawal, with 13/20 given fixed rate chlordiazepoxide regimes. Post-intervention group: 42 patients identified as at risk of withdrawal (4 patients excluded as data incomplete) with 32/38 given symptom-guided regimes.
Analysis by intention to treat showed length of stay reduced from a median of 5 to 3 days post intervention (Mann Whitney u, 2-tailed p = 0.047). Analysis on a per-protocol basis, showed length of stay reduced from (median) 6 days in fixed rate pre-intervention group (N = 13) to 3 days symptom-guided post-intervention group (N = 32) (2-tailed p = 0.021). Median chlordiazepoxide use per patient post-intervention (per-protocol) was 65 mg/24 hrs compared with median 110 mg/24 h pre-intervention, p = 0.012). Seven of 13 post-intervention patients required no chlordiazepoxide. There were no adverse events in either group. Thirteen of 15 (86.7%) nursing staff on AAU found the CIWA(Ar) score/symptom guided withdrawal regimen ‘easy’ or ‘moderately easy’ to use.
Conclusion The symptom-guided withdrawal regimen was readily introduced to a busy AAU in a DGH with no adverse events, and was accompanied by substantially reduced length of hospital stay and amount of chlordiazepoxide used, with positive feedback from nursing staff.
Disclosure of interest None Declared.
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