Experience With an Adult Alcohol Withdrawal Syndrome Practice Guideline in Internal Medicine Patients

Karen M. Stanley, MS; Cathy L. Worrall, PharmD, FAPhA; Shayna L. Lunsford, MS; Kit N. Simpson, Dr.PH; Justin G. Miller, MD; Anne P. Spencer, PharmD


Pharmacotherapy. 2005;25(8):1073-1083. 

In This Article


Inclusion criteria for patients eligible to be in the pilot group (i.e., those treated according to the practice guideline) were admission to the internal medicine service and at least one of the following: a score of at least 2 on the CAGE (cut down, annoyed by criticism, guilty about drinking, eye-opener drinks) questionnaire,[7] heavy daily alcohol intake (> 6 drinks), history of AWS, or history of AWS-related seizures. Control patients were identified by documentation in their medical record of a discharge diagnosis of alcohol withdrawal, or therapy with a combination of benzodiazepine, thiamine, folic acid, and multivitamin. A benzodiazepine and these vitamin supplements are commonly prescribed in our hospital for patients with suspected or known alcohol abuse. The controls were patients discharged from the internal medicine service during the 6-month period preceding practice guideline education and implementation. Excluded from the control group were patients treated with oral or intravenous alcohol and those whose medical records were incomplete.

Education about AWS and use of the practice guideline was provided to nurses, physicians, and pharmacists of the pilot unit. The psychiatric consultation liaison nurse and the clinical pharmacy specialist provided initial and continuing education sessions and support to the pilot unit staff. The order sets required to implement the practice guideline were made available through the medical center's Intranet. The AWS flow sheet used for assessment and documentation was available on the pilot unit. The flow sheet includes the AWS type indicator (Figure 1), the nursing documentation form (Figure 2), and the adult AWS practice guideline algorithms (Figures 3 and 4).

Nursing documentation flow sheet. (Adapted from reference [5].)

Alcohol withdrawal syndrome practice guideline algorithm for treatment of type A and B symptoms.

Alcohol withdrawal syndrome practice guideline algorithm for treatment of type C symptoms and instructions for use of the guideline.

Data collection involved patient demographics (age, sex, race or ethnicity), information about hospitalization (principal diagnosis, admission unit, attending physician), pertinent medical history (comorbid substance abuse, previous AWS, alcohol-related seizures), information about alcohol intake (daily consumption based on patient report and confirmed by family or friends, intoxication at admission, CAGE score for pilot patients), alcohol withdrawal symptoms (type A, B, and C symptoms) in pilot patients, adverse events (withdrawal seizures, cardiovascular events, transfer to intensive care unit), and treatment outcomes (amount of drug administered, use of sitters or restraints, hospital LOS, tapered drug therapy at discharge).

Continuous data were assessed using a 2-tailed t test; nominal data were assessed using a χ2 analysis and Fisher exact test. Total drug doses and use of sitters and restraints were analyzed with nonparametric statistics (Wilcoxon-Mann-Whitney test) since these data were not normally distributed. To control for the confounding effect of medical conditions on hospital LOS, an expected LOS was assigned to each patient. Expected LOS was defined as the average LOS for patients with the same International Classification of Diseases, Ninth Revision (ICD-9) code for the principal diagnosis, and a combined ICD-9 code related to alcohol abuse. The data to construct this variable came from the South Carolina hospital discharge data set. To control for possible selection bias, LOS was transformed and analyzed using the Heckman transformation.

Oxazepam was frequently used to treat patients in the comparison group. To facilitate comparison with the pilot group, all doses were converted to lorazepam equivalents using a 15:1 conversion factor.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.