Pharmacological management of alcohol withdrawal in a general hospital

AIMS AND METHOD

To assess the quality of prescriptions for alcohol detoxificationand vitamin prophylaxis for in-patients who were alcohol-dependentin a general hospital, before and after the introduction ofprescribing guidelines. We assessed 27 prescription chartsbefore and 22 after intervention against standards based onnational guidelines.

RESULTS

There was an increase of 43% (95% CI 20–65%) in the proportionof alcohol detoxification prescriptions that met the guidelines.For vitamin prophylaxis there was an increase of 64% (95% CI42–85%).

CLINICAL IMPLICATIONS

The pharmacological management of alcohol withdrawal in thegeneral hospital can be significantly improved by promotingand making readily available a prescribing guideline. In turn,this may reduce alcohol-related brain damage.

Introduction

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Introduction

Alcohol-related illness is of increasing significance to thehealth service, costing up to £1.7 billion per year (Cabinet Office, 2003).In general hospitals, 15–20% of adult in-patients arealcohol-dependent (Mayo-Smith et al, 2004). Alcohol withdrawal,if not recognised and adequately treated, can progress to deliriumtremens, which causes death in up to 5% of cases (Lishman, 1998).

Poorly managed alcohol detoxification can cause distress toindividuals and their carers, and increase referral rates toliaison psychiatry services. Individuals who have undergoneinadequate detoxification are less likely to engage in subsequentalcohol rehabilitation. Thiamine deficiency secondary to alcoholdependency can lead to permanent neurological damage such as Wernicke–Korsakoff syndrome. Individuals with this conditionfrequently require permanent institutional care – costlyand potentially avoidable through the appropriate vitamin prophylaxis (Royal College of Physicians, 2001). Appropriate alcohol detoxificationand vitamin prophylaxis are crucial in preventing these problems.

Guidelines for the pharmacological management of alcohol withdrawalhave been published by the Royal College of Physicians (2001)and the British Association of Psychopharmacologists (Lingford-Hughes et al, 2004).Generally, benzodiazepines in combination with vitamin prophylaxisare suitable for alcohol detoxification regimes.

The aim of this study was to audit the quality of prescriptionsof alcohol detoxification and vitamin prophylaxis for in-patientswith alcohol dependency in a general hospital, before and afterthe compilation and dissemination of prescribing guidelines.

Method

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Method

Setting
The audit was undertaken on the medical and surgical wards ofa district general hospital in south London. The hospital hasapproximately 600 beds, 195 junior doctors and a catchmentarea of about 300 000 people. This suburban area has districtsof relative affluence interspersed with more deprived ones; a mean index of social deprivation is 15.9 (Office of the Deputy Prime Minister, 2004).

Standards
We established standards for alcohol detoxification and vitaminprophylaxis based on guidelines published by the Royal Collegeof Physicians (2001) and the British Association of Psychopharmacologists (Lingford-Hughes et al, 2004).

For alcohol detoxification, prescriptions met the standard ifeither chlordiazepoxide or diazepam was prescribed as a reducingregimen for an adequate duration. For vitamin prophylaxis,prescriptions met the standard if the dose, route and durationmet with the guidelines.

Intervention
We compiled a written prescribing protocol and distributed itin the hospital. The protocol was based on national guidelinesadapted as suggested by the hospital pharmacists. The guidelinesfor alcohol detoxification are shown in Table 1 and those for vitamin prophylaxis in Table 2.

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Table 1. Guidelines for alcohol detoxification¹

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Table 2. Guidelines for vitamin prophylaxis

The protocol was published in the hospital’s handbookof medical emergencies issued to junior doctors. It was alsoprinted on laminated A4 sheets and placed at visible siteson all medical and surgical wards. The protocol was includedin teaching sessions on alcohol provided for junior doctorsby the liaison psychiatry team.

Audit cycles
During the audit, ward staff and hospital pharmacists helpedto identify in-patients who were alcohol-dependent. The secondaudit cycle was conducted 9 months after the intervention.We analysed 27 prescription charts in the first audit cycleand 22 charts in the second cycle. Data were analysed for significantchanges in prescribing patterns.

Results

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Results

In the first audit cycle, 13 out of 27 prescriptions (48%) metthe standard for detoxification. In the second cycle, 20 outof 22 met the standard (91%), an improvement of 43% (95% CI20–65%).

The standard for vitamin prophylaxis was met in 5 out of 27prescriptions (19%) in the first audit cycle and in 18 outof 22 prescriptions (82%) in the second cycle, an improvementof 64% (95% CI 42–85%).

Discussion

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Discussion

Our audit showed that the compilation and distribution of prescribing guidelines led to improvements in the pharmacological managementof alcohol withdrawal in in-patients in general hospital.

An audit by McIntosh et al (2005) also showed improvements in patient management after the introduction of prescribingguidelines but they looked specifically at the prescriptionof parenteral thiamine in a psychiatric setting. They foundthat including information on the identification and treatmentof Wernicke–Korsakoff syndrome in hospital prescribingguidelines improved prescribing. Our audit extends the interventionby including guidelines on alcohol detoxification and showsits use in a general hospital.

The Royal College of Physicians (2001) identified key areas that act as barriers to the effective treatment of individualswho are alcohol-dependent. These are a lack of education andtraining for hospital staff, organisational barriers and negativeattitude in staff. Our intervention and audit were aimed ataddressing the first two of these barriers.

Prescribing for in-patients with alcohol dependency is oftenthe task of junior doctors. However, during the audit we confirmeda relative lack of knowledge about the management of alcoholdependency among this group, which may reflect a gap in undergraduatemedical education. Of note, the British National Formulary(2007), an important source of information on prescribing,does not include detailed prescribing regimes for alcohol detoxificationand vitamin prophylaxis.

Limitations
The audit was specifically designed for a single general hospital,which may limit extrapolation of the findings to other settings.We did not seek to identify in-patients who were alcohol-dependentthat were not diagnosed as such on admission. The adequacyof prescriptions may therefore be overestimated. Also, we didnot identify which components of the interventions were themost powerful in triggering change, namely, promoting the guideline at teaching sessions, including it in the hospital handbookof medical emergencies or displaying it on the wards (e.g.on notes trolleys and nursing stations). Further audit cycleswould be required to see whether the benefits of the introductionof the prescribing protocol have been maintained.

Prescribing guidelines can help to improve the pharmacologicalmanagement of alcohol-dependency in general hospital in-patients.This may lead to more individuals subsequently engaging withinterventions for alcohol dependency and reduce alcohol-relatedbrain damage.

Acknowledgments

We thank the ward staff and hospital pharmacists who assistedwith the audit and Sarah White, medical statistician at StGeorge’s University of London, who advised on data analysis.

References

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