A Risk Stratification Approach to Alcohol Detoxification

The challenges of identifying patients at risk for alcohol withdrawal have been found to be mitigated by the development of a Risk Stratification Questionnaire, employed by the VA in West Haven, Connecticut. It is now being adopted by the VA regionally throughout New England. Dr Nick Mellos describes more in this brief video.

With Louis Trevisan, MD, Dr Mellos spoke at the American Psychiatric Association Institute on Psychiatric Services meeting in Philadelphia in a presentation titled “Alcohol Detoxification: A Risk Stratification Approach.”

Dr Mellos is Assistant Clinical Professor of Psychiatry at Yale School of Medicine in New Haven, Connecticut, and Director of the Psychiatric Emergency Room at VA Connecticut. He reports he was a consultant for Navigant (Formally Easton Associates LLC).

Transcript
A number of years ago at VA Connecticut, we had identified that there was a large patient population that was presenting needing alcohol detox, and we had identified that there were varied practice patterns that we had identified a great deal of restraint utilization with [patients] who had alcohol use disorders. There was also a large prevalence of alcohol use disorders within inpatient medicine psychiatry and the emergency departments.

We developed a larger multidisciplinary team to come up with a best practice approach at managing alcohol detoxification. That included bringing in people from internal medicine, from various departments of nursing, and psychiatry to come together, review the literature, and look to see what is the best practice . . . to improve alcohol detoxification at VA Connecticut.

That eventually resulted in the development of the Risk Stratification Questionnaire because our impressions were to try to identify patients that are at high risk for withdrawal and try to treat them more aggressively with the hope that would improve outcomes. The Risk Stratification [Questionnaire] was implemented in 2010 after testing it on 125 patients. We made fine tuning adjustments as we went along, and it was rolled out after that. Along those lines, we also looked at pharmacology . . . to identify that the best pharmacological approach was.

For us at VA Connecticut, because of our medical comorbidity within the complex veteran population that we serve, we chose lorazepam as our base pharmacological agent for detox. [The reason for this was] because of its short half life, it is pharmacologically clean, and you can take your foot off the gas if you [feel you are] are overmedicating a person. [This is] not true for longer acting agents like diazepam and chlordiazepoxide.

Retrospectively, a number of years later, we examined the outcomes of veterans who were stratified, and it indicated that we were on the right track. We had no incidence of delirium tremens (DTs) in our low-risk stratified group; we had just a couple in the moderate-risk group; and the majority of incidences in DTs in restraints were concentrated in the higher risk group as expected.

We feel overall that our approach has been an improvement to what we were doing before and is certainly heading in the right direction in regards to better managing alcohol detox.

Working as a team for best outcomes
One of the challenges is identifying patients at risk. In an age where [a lot] is asked from staff (eg, JHACO [Joint Commission on Accreditation of Healthcare] requirements, and a lot of things that staff feel they have to do-there is a sense that it takes time and pulls time away from clinical care . . . how do you add another burden to the staff?

Our approach to addressing that was bringing the data, bringing our initial review of VA Connecticut alcohol prevalence and restraint use, and that questionnaire which brought to the forefront to leadership [and to a lot of different providers] a true sense of the burden of alcohol use disorder at VA Connecticut.

Once that was established, it was a no brainer . . . we had to something more. Nursing at that point was great. They took ownership of it and implemented a hospital-wide alcohol screening for everybody coming in for either the emergency department or to the inpatient unit. So that was the approach we took to insure that was conducted and I think this has been essential in the success of our work at VA Connecticut and alcohol detox.

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