Spotting alcohol-dependent patients improves care

CQI team develops effective assessment tools

By Linda Ryan, RN, CARN, MA

Manager of the medical-surgical unit

Resurrection Medical Center, Chicago

Two assessment instruments developed at Resurrection Medical Center have significantly improved the standard of care for patients dependent on alcohol, while improving utilization management for those patients. The tools were produced through a collaboration between addiction specialists and bedside clinicians.

Alcohol withdrawal management cannot wait until medical-surgical problems are stabilized. These special tools help the medical staff recognize and manage alcohol withdrawal and stabilize the patient simultaneously.

Using the instruments appropriately can both significantly improve outcomes and reduce treatment costs for the alcohol-dependent patient. Approximately 20% to 50% of general hospital admissions can be alcohol related.1 However, clinicians practicing in hospital settings frequently are not trained to adequately manage this syndrome. Addiction education in basic medical and nursing preparation programs is minimal. Less than 1% of medical instruction is concentrated in the field of chemical dependency, and nursing schools typically devote only a few hours to the subject.2,3 With such lack of training, how can the clinician recognize the signs and symptoms of alcohol dependency and monitor the patient for the withdrawal syndrome? As a further stumbling block, the clinician’s own perspectives and prejudices about alcohol dependence may interfere with proper disease management.

CQI team forms

A significant portion of the patients admitted with surgical problems to Resurrection Medical Center, a large community teaching hospital on the northwest side of Chicago, have underlying alcohol dependency issues. Managing these patients’ concurrent addictions while treating their presenting condition represented a challenge, so we developed a CQI team to analyze the issue. The team consisted of the medical QI chairperson, the nursing manager of medical services — a certified addictions registered nurse — the nursing manager of the intensive care services, a staff psychiatrist board certified in addictions, and an addictions counselor who is the director of the outpatient addiction treatment center. The tools the team developed objectively assess the withdrawal process and guide treatment management.

As a baseline, we conducted a chart review of 53 patients admitted with primary or secondary diagnoses of alcohol-related problems. That review substantiated the need for following two alcohol dependency disease management tools the team developed:

Treatment protocol for alcohol withdrawal prevention.

Order lab work, and take vital signs frequently to assess for signs of hyperneural activity, such as tachycardia, hypertension, and hyperthermia. To manage withdrawal, give valium both on a weaning and prn schedule. If the patient is unable to take valium orally, the sedative of choice is Ativan IM. (See physician’s orders, inserted in this issue.) If a patient needs prn medication for more than four consecutive hours, notify the physician for dose adjustment. Administer vitamins to treat malnutrition and associated neurological deficits. Refer to addiction treatment services for counseling and after care, an important component for this biopsychosocial illness.

Alcohol withdrawal scale.

This is an adaptation of a measurement device developed by the American Society of Addiction Medicine to specifically measure physiological effects of the alcohol withdrawal syndrome. The goal of withdrawal management is to provide appropriate sedation to wean the patient off the central nervous system depressant while preventing escalation into severe withdrawal. (See withdrawal scale and guidelines for using the scale inserted in this issue and p. 102.) By correlating deviation of vital signs with the alcohol withdrawal scores, the tool serves as a guide for the administration of prn sedation.

Chronic alcohol use affects every system of the body. Patients with underlying alcohol problems can be found in every specialty area, so these tools are available throughout the institution. Our team taught each nursing unit about alcohol dependency and how to use the forms.

Prevent DTs, and you lower costs

Six months into the program, we again reviewed patient charts. In keeping with the design of the first study, all charts of patients admitted with primary or secondary diagnoses of alcohol-related problems were examined. The results were:

Significant performance improvements.

When the alcohol-withdrawal protocol was used in conjunction with the nursing assessment tool, no patients escalated into severe withdrawal — delirium tremens (DTs). In the initial study, 41% had experienced DTs. This was a notable improvement because by averting DTs, you decrease mortality rate, contain treatment costs, and improve patient dignity by eliminating the need for restraints. Up to 15% of patients can die from the withdrawal process, and patients who escalate into severe withdrawal require intense nursing and medical resources. They often need protective devices, restraints, and private duty sitters. The severity of their illnesses may even demand intensive care services.

Improved continuum of care.

Because the protocol mandated referral to addiction treatment services, there was a 14% improvement in offering aftercare programs. Researchers have found that patients in aftercare programs stay sober longer than those who do not participate in such programs.4

Decreased length of stay.

Our average length of stay in the pre-program population was 1.1 days longer than in the post-program population. This represents a substantial cost savings for the medical center, for insurance carriers, and for patients.

References

1. Fleming M, Barry K, Davis A, et al. Medical education about substance abuse: Changes in curriculum and faculty between 1976 and 1992. Academic Medicine 1994; 69:362-369.

2. Hoffman A, Heinemann ME. Substance abuse education in schools of nursing: Anational survey. Journal of Nursing Education 1987; 267:282-287.

3. Durfee M, Warren D, Sdao-Jarvie K. A model for answering the substance abuse educational needs of health professionals: The North Carolina governor’s institute on alcohol and substance abuse. Alcohol 1994; 11:483-487.

4. Kelly V, Banta Kroop F, Manhal-Baugus M. The association of program-related variables to length of sobriety: A pilot study of chemically dependent women. Journal of Addictions and Offender Counseling 1995; 15:42-50.