An audit of the pharmacological management of patients experiencing acute alcohol withdrawal at a large tertiary centre
Authors: Hampton E , Saggu R , Gondongwe X D , Mamdani F 
Published: November 2022

Abstract

Introduction
Alcohol has depressant effects on the central nervous system through its effect on inhibitory GABAA receptors. In chronic excessive alcohol use, GABAA receptors undergo neuroadaptation, and so, in abrupt alcohol withdrawal upon admission into hospital, the central nervous system remains in a hyperactive state, resulting in alcohol withdrawal syndrome (AWS), and can progress to seizures and delirium tremens if not managed appropriately. National guidance recommends validated tools such as the ‘Clinical Institute Withdrawal Assessment – Alcohol, revised’ (CIWA-Ar) scale and use of benzodiazepines and thiamine for AWS management. Within our organisation, pharmacists and the Alcohol and Drug Liaison Nurse (ADLN) specialists have noted variability in AWS management.

Aim
This project aimed to investigate the compliance to local and national guidelines in the management of AWS.

Methods
A retrospective audit (for which ethical approval was not required) was conducted using the electronic health record system to identify high-risk drinkers on the acute medical unit (AMU). A report of AMU admissions from 1st to 30th April 2020 was obtained and identified 44 patients with AWS. Patient records were analysed to assess compliance to the following standards: Standard 1 was that 100% of patients must have a completed AUDIT-C form on admission; Standard 2 was that 100% with AWS must have a CIWA-Ar score recorded every 4 hours on day one; Standard 3 was that 100% must be prescribed a benzodiazepine reducing regimen as per guidelines; and Standard 4 was that 100% with malnourishment or who will continue to consume alcohol must be discharged with thiamine 200-300mg daily.

Results
For Standard 1, 2% of patients (n=1) had AUDIT-C forms completed. For Standard 2, 14% (n=6) had a CIWA-Ar score measured every 4 hours on day one. For Standard 3, 23% (n=10) were prescribed benzodiazepine fixed-dose reducing regimens according to their CIWA-Ar score. 23% (n=10) had no benzodiazepines prescribed and 30% (n=13) were only prescribed a ‘when required’ benzodiazepine. 48% (n=21) were prescribed a regular benzodiazepine initially rather than a reducing regimen. Of these, 62% (13/21) were commenced on an appropriate dose according to their CIWA-Ar score. For Standard 4, 34% (n=15) were discharged on oral thiamine 200-300mg daily. 27% (n=12) were discharged without thiamine.

Discussion/Conclusion
The use of AUDIT-C forms was not routine practice. This may lead to under-detection of patients experiencing AWS resulting in treatment delays. CIWA-Ar scores were rarely carried out every 4 hours on day one, perhaps highlighting a need for guidance on frequency of CIWA-Ar assessment. Ten patients with AWS were not prescribed a benzodiazepine. This could have been due to a lack of awareness of guidelines, or that simplification of current guidelines is required. Limitations of this audit include that it did not explore clinical reasons for deviations from guidelines or any additional specialist advice sought from ADLN. As such, it cannot be assumed that all deviations from guidelines were inappropriate. No audit standards were met, highlighting a need to improve management of AWS in a hospital setting.

References
1. NHS Digital. Statistics on Alcohol, England 2019 [PAS] [Internet]. 1 February 2019. [accessed 12 May 2021]; Available from: https://digital.nhs.uk/data-andinformation/publications/statistical/statistics-on-alcohol/2019
2. Kumar S, Porcu P, Werner D, Matthews D, Diaz-Granados J, Helfand R et al. The role of GABAA receptors in the acute and chronic effects of ethanol: a decade of progress. Psychopharmacology [Internet]. 2009 [cited 30 July 2022];205(4):529-564. Available from: https://link.springer.com/article/10.1007/s00213-009-1562-z
3. National Institute for Heath and Care Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking and alcohol dependence [internet]. 02 June 2010. [accessed 30 July 2022]; Available from: https://www.nice.org.uk/guidance/cg100/chapter/Recommendations#acute-alcohol-withdrawal