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Identifying problem drinkers on admission improves care
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protocol that identifies problem drinkers when they are admitted to the hospital is enabling doctors to intervene before patients develop alcohol withdrawal. Rolled out in October 2009, the results are dramatic, with a significant reduction in length of stay and disruptions caused by patients suffering from withdrawal. “Alcohol use is common,” says Terry Horton, M.D., of the Department of Medicine. “It’s a safety issue not only for the patient, but for the people caring for the patient.” “Because of the stigma of alcoholism, an important medical problem was often pushed aside,” says Julie Silverstein, M.D., director, Department of Medicine Patient Safety and Performance Improvement. “This program acknowledges the high rate of alcoholism in the community and allows for safe intervention.” Every patient screened Now, Christiana Care nurses screen every patient admitted, using the Alcohol Withdrawal Risk Assessment. Once the assessment is ordered by a physician, nurses assess patients at risk for withdrawal severity under Alcohol Withdrawal Care Management Guidelines (CMG). The CMG include an assessment tool used to evaluate, determine the appropriate dose of medication, monitor for response and adjust dosing accordingly. Wilmington Hospital typically has three patients under alcohol withdrawal management at any given time. The Computerized Provider Order Entry system includes an Alcohol Withdrawal power plan, which is currently the sixth most common power plan ordered.
In the months since the program was launched, diagnoses of withdrawal are up and cases of DTs are down. The use of restraints has declined and transfers to the intensive care unit for DTs as a secondary diagnosis have fallen. Early trends suggest a dramatic reduction in length of stay for patients who receive indicated interventions for potential alcohol withdrawal. Some findings have been surprising. Two-thirds of DTs cases are secondary diagnoses, with primary diagnoses such as pneumonia or kidney disease. Nearly one in four of these patients is 65 or older. Dr. Horton notes that developing the protocol was a dynamic, multidisciplinary initiative involving a team of nurses, pharmacists and physicians working with performance improvement, data acquisition and informa-
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Sources: Delaware Department of Health and Social Services, Division of Public Health and the
Identifying problem drinkers at time of admission enables doctors to intervene before patients develop alcohol withdrawal.
tion technology staff. The program was a grassroots effort, grounded in concerns raised by nurses for patients who were not identified as problem drinkers at admission who subsequently went into alcohol withdrawal. “One of the nurse managers was extremely frustrated because a patient had barricaded himself in the waiting room at 2 o’clock in the morning,” recalls Jo Melson, APN, a nurse practitioner. “These types of outbursts were commonplace and very disruptive.” The protocol is attracting attention elsewhere in the health care community. In July, Melson and nurseresearcher Ruth Mooney, Ph.D, presented “Show me the Evidence— Improving Alcohol Withdrawal Outcomes in Acute Care” at the University of Texas 2010 Summer Institute for Evidence-Based Practice in San Antonio. Dr. Horton says the program has farreaching possibilities for certain patients. “The hospital can be the place that establishes linkage toward recovery,” he says.