Poor management of alcohol withdrawal in inpatients can be detrimental to staff as well as other patients. A tool improved the management of a challenging patient group
An estimated 40% of patients admitted with alcohol-related problems to Glasgow hospitals are at risk of alcohol withdrawal syndrome (AWS). Not managing them effectively can affect the physical and psychological wellbeing of staff and other patients. This article describes the development and implementation of a tool, the Glasgow Modified Alcohol Withdrawal Scale, to manage patients with AWS. It is part of a more comprehensive assessment and management protocol and incorporates a protocol to help nurses decide whether to administer fixed-dose or symptom-triggered benzodiazepine to these patients.
Citation: Benson G et al (2012) An alcohol withdrawal tool for use in hospitals. Nursing Times; 108: 26, 15-17.
Authors: George Benson is nurse team leader; Andrew McPherson is senior addictions nurse; Steven Reid is senior addictions nurse; all in the acute addiction liaison nurse team, Glasgow Addiction Services, Glasgow.
- This article has been double-blind peer reviewed
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The number of patients admitted to acute general hospitals in the UK with alcohol-related problems has doubled since 2002-03 (Mayor, 2010). In Scotland, this is estimated to be in the region of 39,000 per year, with around one third admitted to hospitals in the Greater Glasgow and Clyde area. Admission due to alcohol intoxication costs the Scottish economy between £0.7m and £1.95m per year (Griesbach et al, 2009).
Admissions associated with secondary problems from alcohol misuse have increased (National Institute for Health and Clinical Excellence, 2010) and in at least 40% of alcohol-related admissions, patients will experience alcohol withdrawal in hospital.
Poor management of withdrawal can adversely affect patients’ health, as well as the physical and psychological wellbeing of staff and other patients. There is also an increased risk of aggression or violence towards staff. A safe and efficient tool to identify and manage patients with AWS in acute general hospitals is needed.
Alcohol withdrawal syndrome
Alcohol is a central nervous system depressant, and abrupt cessation in people who drink heavily overstimulates the autonomic nervous system. This overstimulation – AWS – runs from mild and moderate to culminate, in severe cases, in alcohol withdrawal seizures and delirium tremens (DTs).
Mild to moderate withdrawal appears on a continuum. It begins with an autonomic response and includes tremors, sweating, nausea, vomiting, tachycardia and hypertension before progressing to neuropsychiatric symptoms of anxiety, psychoses, agitation and seizures. Symptoms usually appear 6-24 hours after the last drink (Heymann et al, 2010). In most instances, symptoms are proportionate to the amount of alcohol consumed and the length of the drinking pattern (Bayard et al, 2000).
A more critical outcome of AWS can be DTs, which can be fatal.
Alcohol withdrawal tools
Before the Glasgow Modified Alcohol Withdrawal Scale (GMAWS) was developed, Glasgow hospitals relied on the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) (Sullivan et al, 1989). Although this tool has been extensively researched and is recognised as the gold standard (Williams et al, 2001), most of the research took place in alcohol detoxification centres (Swift et al, 2010; Foy et al, 2006; Sullivan et al, 1989).
In Glasgow hospitals, at least eight versions of the CIWA-Ar were in use, with varying guidance notes. This resulted in inconsistency in patients’ management, which led to alcohol-related violent incidents. Moreover, the CIWA-Ar was thought to be too complex and incompatible with nursing duties, which are time driven.
Some have questioned whether the tool is suitable for use in acute general hospitals (Hecksel et al, 2008). Bostwick and Lapid (2004), for example, suggested that it is incompatible for use in acutely ill patients, as AWS can mask other disease modalities.
Tackling the problem in Glasgow
Given the above, we set up a working group to develop a screening tool and guidance for use in acute hospital settings. The GMAWS identifies alcohol misuse and dependency in acute hospital patients (Fig 1); it also provides a simplified score to assess level of AWS, as well as vitamin prophylaxis and treatment of Wernicke-Korsakoff syndrome. This is associated with a severe deficiency of thiamine (vitamin B1) in people who chronically misuse alcohol. Thiamine is a cofactor in the metabolism of glucose and deficiency can result in an inflammatory degenerative condition of the brain.
The Glasgow Assessment and Management of Alcohol Guideline (GAMAG) aims to assist staff in selecting treatment pathways for AWS and other comorbidities (Fig 2).
The GMAWS tool
The GMAWS, a five-variable assessment tool to manage AWS in acute hospitals, is a modification of two AWS tools (Swift et al, 2010; Foy et al, 2006). Information from the study by Swift et al (2010) and the influence that conditions such as sepsis can have on temperature led to the temperature score being removed from the final tool. The tool recommends doses of diazepam as well as time intervals between assessments.
Studies comparing symptom-triggered treatment of AWS with fixed-dose treatment have concluded that symptom-triggered benzodiazepines treatment for AWS is safe. It is also associated with shortened hospital stays and a concurrent reduction in medication compared with a fixed-dose regimen (Daeppen et al, 2002). Improved outcomes are evident in patients experiencing DTs who are treated with symptom-triggered benzodiazepine regimens with a front-loading dose of the drug (Daly and Muyeba, 2008). However, most UK hospitals prescribe fixed-dose regimens.
Guideline to support the GMAWS
The GAMAG allows for withdrawal risk to be assessed by identifying whether patients are at high or low risk of AWS, which determines benzodiazepine administration. Fixed-dose diazepam plus symptom-triggered treatment is recommended for patients at high risk, while symptom-triggered treatment is recommended only for those at low-risk. High-risk patients present with two or more of the following:
- Current or previous presentation with withdrawal seizures;
- Previous severely agitated withdrawal or delirium tremens;
- High alcohol screening score;
- High initial symptom score (GMAWS >8).
- At the extreme end of AWS, parenteral administration of medication (intravenous benzodiazepines or haloperidol) can be carried out.
The guideline also considers patients at high-risk of complications associated with benzodiazepines (such as older patients or those with advanced liver disease).
The screening tool and guidance were introduced to all 33 wards and specialties at Glasgow Royal Infirmary, and data collected over five months in 2009-10.
A staff evaluation was carried out; 130 forms were distributed and 45 (34.6%) returned. Forty one (91%) respondents found the documentation “excellent”, “very good” or “good”; 33 (75.5%) described the GMAWS as “very easy” or “quite easy” to use, with none finding it difficult to use.
Most failures concerning the management of AWS in acute hospitals are associated with time constraints, but 34 (76%) of respondents felt there was enough time to complete the GMAWS. More significantly, 32 (71%) said that the document improved the management of alcohol withdrawal.
Before the study, the average length of stay for patients with an alcohol-related diagnosis was 7.5 days. Following intense training in parallel with the introduction of GMAWS, this fell to 5.8 days in 2009-10. This equates to a reduction of 23%. Before the study and the introduction of the guideline, 17 violent incidents were recorded in the same period for the previous 12 months. This fell to seven during the study period.
AWS management in the UK varies and a standard guideline is needed. Variation has been addressed in secondary care with the GMAWS and its guidance and the targeted approach by the acute addiction liaison service in Glasgow. These provide comprehensive recommendations for assessment and treatment, with the AALS maintaining the momentum. The tool’s ease of use and application to hospital practice are important, and its anticipatory nature makes it effective in AWS management, particularly for patients admitted for other reasons.
The comprehensive assessment of risk of severe AWS allows nurses to use fixed-dose and symptom-triggered regimens in a more targeted manner; a key benefit is that patients can start treatment. This relies on their initial assessment, which incorporates their original screening score and GMAWS value. Moreover, the tool includes history of previous agitated AWS or a current or previous history of alcohol withdrawal seizures.
The guideline’s success and effectiveness are due to education and support given to nursing and medical staff by the AALS. Although adherence was not always perfect – ease of use helped – nurses showed success in managing AWS.
This guideline appears to have improved management of a challenging patient group, as well as patients’ hospital journey. This is evident in the shorter length of stay and the reduction in alcohol-related violence. The guideline has been ratified for use in the Greater Glasgow and Clyde Health Board acute hospitals.
- The number of patients admitted to acute hospitals with alcohol-related problems is growing
- Alcohol withdrawal syndrome can have an adverse effect on the health of hospital patients
- It can also affect the wellbeing of staff and other patients
- The most commonly used AWS screening tool was tested in alcohol detox settings, so one was needed for acute hospitals
- Early identification of AWS can cut length of hospital stays and the number of violent incidents
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