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IMV 04-094 – HSR&D Study

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IMV 04-094
Preventing Alcohol Withdrawal Syndrome in Medical and Surgical Patients
Kenneth R. Weingardt PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: January 2004 - June 2004

BACKGROUND/RATIONALE:
Alcohol Withdrawal Syndrome (AWS) represents a serious threat to the well-being of a substantial portion of medical, surgical, and critically ill VA patients, and results in unnecessary, costly medical care expenditures. Severe AWS has been associated with mortality rates ranging up to 40%. Even in less severe cases, failure to provide prophylactic treatment for alcohol withdrawal can change a normal postoperative course into a life-threatening situation in which the alcohol dependent patient requires intensive care. Training medical and nursing staff to objectively monitor the severity of AWS risk has been found to significantly improve patient outcomes. In fact, using an objective measure to screen for risk of AWS is a key recommendation in the “Veterans Health Administration/Department of Defense Clinical Practice Guidelines for the Assessment and Management of Substance Use Disorders in Primary and Specialty Care”.

OBJECTIVE(S):
The long term objective of this work is to facilitate implementation of evidence-based practices to objectively screen medical and surgical patients for risk of Alcohol Withdrawal Syndrome. Achievement of this objective will require modification of existing processes of care in order to incorporate the regular and systematic use of an objective screening measure such as the Clinical Institute for Withdrawal Assessment – Alcohol, Revised (CIWA-Ar). The primary short term goal of his planning grant is to gain an understanding of existing processes of care for patients at risk of developing AWS. Information about existing processes of care will then be used to inform a implementation study evaluating an integrated intervention that will (a) train nursing staff in the use of the CIWA-Ar or similar measure to identify patients who are likely to experience AWS and (b) recommend best practices for medical management of patients so identified.

METHODS:
A Registered Nurse Practitioner will network and establish relationships with key stakeholders in the various medical and surgical wards within the VA Palo Alto Health Care System. The objective of these meetings will be to initially identify cases of AWS. The RNP will subsequently conduct in-depth case reviews of patients so identified. Further discussion with relevant nursing staff will elicit their perspectives on the target cases, their thoughts about how existing processes of identifying patients at risk for AWS may be sub-optimal, and their recommendations how they could be improved. Initial meetings will be qualitative and open-ended, allowing respondents to freely communicate those factors that they think are most important. Over the course of this three-month planning project, we expect the interviewing methods to become increasingly structured and focused.

FINDINGS/RESULTS:
The project RNP was hired on 9/2/04. To date, she has become familiar with the academic literature on AWS, and its identification and treatment. She has also met with a Clinical Nurse Specialist representative of the Office of Quality Management who provided her perspective about the advantages and disadvantages of implementing this intervention in various clinical settings ranging from ICU to medical and surgical wards. The OQM representative has expressed interest in ongoing collaboration and is facilitating an introduction with the Director of Inpatient Medical and Surgical Nursing, as well as introductions to staff of clinical settings that may be a productive focus of future efforts.

IMPACT:
Alcohol Withdrawal Syndrome (AWS) represents a serious threat to the well-being of a substantial portion of surgical, trauma and acutely ill VA patients, and results in unnecessary, costly medical care expenditures. Severe AWS has been associated with mortality rates ranging up to 40%. The primary impact of this project is to prevent the mortality and morbidity associated with AWS in the population of hospitalized veterans. A second important impact is the development of an interactive, engaging and cost effective means of using Web-Based Training for the rapid dissemination of other Clinical Practice Guideline (CPG) recommendations.

PUBLICATIONS:
None at this time.


DRA: Substance Abuse and Addiction, Health Systems
DRE: none
Keywords: Implementation, Screening, Surgery
MeSH Terms: none