Alcohol-related illness is of increasing significance to the health service, costing up to £1.7 billion per year (Cabinet Office, 2003). In general hospitals, 15–20% of adult in-patients are alcohol-dependent (Reference Mayo-Smith and BeecherMayo-Smith et al, 2004). Alcohol withdrawal, if not recognised and adequately treated, can progress to delirium tremens, which causes death in up to 5% of cases (Reference LishmanLishman, 1998).
Poorly managed alcohol detoxification can cause distress to individuals and their carers, and increase referral rates to liaison psychiatry services. Individuals who have undergone inadequate detoxification are less likely to engage in subsequent alcohol rehabilitation. Thiamine deficiency secondary to alcohol dependency can lead to permanent neurological damage such as Wernicke–Korsakoff syndrome. Individuals with this condition frequently require permanent institutional care – costly and potentially avoidable through the appropriate vitamin prophylaxis (Royal College of Physicians, 2001). Appropriate alcohol detoxification and vitamin prophylaxis are crucial in preventing these problems.
Guidelines for the pharmacological management of alcohol withdrawal have been published by the Royal College of Physicians (2001) and the British Association of Psychopharmacologists (Reference Lingford-Hughes, Welsh and NuttLingford-Hughes et al, 2004). Generally, benzodiazepines in combination with vitamin prophylaxis are suitable for alcohol detoxification regimes.
The aim of this study was to audit the quality of prescriptions of alcohol detoxification and vitamin prophylaxis for in-patients with alcohol dependency in a general hospital, before and after the compilation and dissemination of prescribing guidelines.
Method
Setting
The audit was undertaken on the medical and surgical wards of a district general hospital in south London. The hospital has approximately 600 beds, 195 junior doctors and a catchment area of about 300 000 people. This suburban area has districts of 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 vitamin prophylaxis based on guidelines published by the Royal College of Physicians (2001) and the British Association of Psychopharmacologists (Reference Lingford-Hughes, Welsh and NuttLingford-Hughes et al, 2004).
For alcohol detoxification, prescriptions met the standard if either chlordiazepoxide or diazepam was prescribed as a reducing regimen for an adequate duration. For vitamin prophylaxis, prescriptions met the standard if the dose, route and duration met with the guidelines.
Intervention
We compiled a written prescribing protocol and distributed it in the hospital. The protocol was based on national guidelines adapted as suggested by the hospital pharmacists. The guidelines for alcohol detoxification are shown in Table 1 and those for vitamin prophylaxis in Table 2.
Guidelines for alcohol detoxification1
| Starting dose of chlordiazepoxide (daily alcohol consumption) | 15-25 mg (15-25 units) | 30-40 mg2 (30-40 units) | 50 mg QDS2 (50-60 units) | ||
|---|---|---|---|---|---|
| Day 1 (starting dose) | 15 QDS | 25 QDS | 30 QDS | 40 QDS2 | 50 QDS2 |
| Day 2 | 10 QDS | 20 QDS | 25 QDS | 35 QDS | 45 QDS |
| Day 3 | 10 TDS | 15 QDS | 20 QDS | 30 QDS | 40 QDS |
| Day 4 | 5 TDS | 10 QDS | 15 QDS | 25 QDS | 35 QDS |
| Day 5 | 5 BD | 10 TDS | 10 QDS | 20 QDS | 30 QDS |
| Day 6 | 5 nocte | 5 TDS | 10 TDS | 15 QDS | 25 QDS |
| Day 7 | 5 BD | 5 TDS | 10 QDS | 20 QDS | |
| Day 8 | 5 nocte | 5 BD | 10 TDS | 15 QDS | |
| Day 9 | 5 nocte | 5 TDS | 10 QDS | ||
| Day 10 | 5 BD | 10 TDS | |||
| Day 11 | 5 nocte | 5 TDS | |||
| Day 12 | 5 BD | ||||
| Day 13 | 5 nocte | ||||
Guidelines for vitamin prophylaxis
| Patient | Prophylaxis required |
|---|---|
| Incipient Wernicke's encephalopathy (confusion, ataxia and ophathlmoplegia) | Two pairs high-potency thiamine injection1 three times daily for 3 days, followed by one pair once daily for 3-5 days depending on response |
| At-risk (significant weight loss, poor diet, signs of malnutrition) | One pair high-potency thiamine injection1 once daily for 3-5 days |
| Lower risk | Thiamine 200 mg orally, four times daily, plus vitamin B compound strong two tablets three times daily during detox |
The protocol was published in the hospital's handbook of medical emergencies issued to junior doctors. It was also printed on laminated A4 sheets and placed at visible sites on all medical and surgical wards. The protocol was included in teaching sessions on alcohol provided for junior doctors by the liaison psychiatry team.
Audit cycles
During the audit, ward staff and hospital pharmacists helped to identify in-patients who were alcohol-dependent. The second audit cycle was conducted 9 months after the intervention. We analysed 27 prescription charts in the first audit cycle and 22 charts in the second cycle. Data were analysed for significant changes in prescribing patterns.
Results
In the first audit cycle, 13 out of 27 prescriptions (48%) met the standard for detoxification. In the second cycle, 20 out of 22 met the standard (91%), an improvement of 43% (95% CI 20–65%).
The standard for vitamin prophylaxis was met in 5 out of 27 prescriptions (19%) in the first audit cycle and in 18 out of 22 prescriptions (82%) in the second cycle, an improvement of 64% (95% CI 42–85%).
Discussion
Our audit showed that the compilation and distribution of prescribing guidelines led to improvements in the pharmacological management of alcohol withdrawal in in-patients in general hospital.
An audit by McIntosh et al (Reference McIntosh, Kippen and Hutcheson2005) also showed improvements in patient management after the introduction of prescribing guidelines but they looked specifically at the prescription of parenteral thiamine in a psychiatric setting. They found that including information on the identification and treatment of Wernicke–Korsakoff syndrome in hospital prescribing guidelines improved prescribing. Our audit extends the intervention by including guidelines on alcohol detoxification and shows its use in a general hospital.
The Royal College of Physicians (2001) identified key areas that act as barriers to the effective treatment of individuals who are alcohol-dependent. These are a lack of education and training for hospital staff, organisational barriers and negative attitude in staff. Our intervention and audit were aimed at addressing the first two of these barriers.
Prescribing for in-patients with alcohol dependency is often the task of junior doctors. However, during the audit we confirmed a relative lack of knowledge about the management of alcohol dependency among this group, which may reflect a gap in undergraduate medical education. Of note, the British National Formulary (2007), an important source of information on prescribing, does not include detailed prescribing regimes for alcohol detoxification and 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-dependent that were not diagnosed as such on admission. The adequacy of prescriptions may therefore be overestimated. Also, we did not identify which components of the interventions were the most powerful in triggering change, namely, promoting the guideline at teaching sessions, including it in the hospital handbook of medical emergencies or displaying it on the wards (e.g. on notes trolleys and nursing stations). Further audit cycles would be required to see whether the benefits of the introduction of the prescribing protocol have been maintained.
Prescribing guidelines can help to improve the pharmacological management of alcohol-dependency in general hospital in-patients. This may lead to more individuals subsequently engaging with interventions for alcohol dependency and reduce alcohol-related brain damage.
Declaration of interest
None.
Acknowledgements
We thank the ward staff and hospital pharmacists who assisted with the audit and Sarah White, medical statistician at St George's University of London, who advised on data analysis.
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