Shared learning database

Pennine Acute Trust
Published date:
April 2013

Implementing a 'symptom-triggered' approach to the management of alcohol withdrawal in an acute hospital.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

-To uniform practice of alcohol withdrawal
-Improve treatment options for patients
-Implement an integrated care pathway including an assessment tool of withdrawal symptoms (CIWA-ar)
-Improve management for staff

Reasons for implementing your project

Prior to the project an audit of current practice was completed. This audit looked at length of hospital detox in days, what medication was used to aid withdrawal symptoms, how much of the drug was used and whether the patient went on to develop any severe complications of withdrawal. The audit found there was an ad hoc approach to practice with differing medications, different dosing regimens, different length of stay and that some of the cohort did develop more complex symptoms of alcohol withdrawal phenomena. This audit identified the need for change. Practice had to be consistent and safe; a uniformity of treatment options had to be implemented. NICE guidance (CG100), identified the use of a 'symptom-triggered' approach to care. The benefits identified that following this model could achieve were decrease in treatment time, less pharmacology required to complete detox, a patient centred approach to care and improved satisfaction for both staff and patients alike.

How did you implement the project

A project group was created including Consultants, senior nurses and pharmacists. It was agreed that uniforming practice was needed and implementation of a 'symptom-triggered' approach would be useful. It was felt the introduction of an integrated care pathway (ICP) would be an appropriate way to manage this change. An ICP was created incorporating NICE guidance, the ICP included the CIWA-ar assessment tool and an easy to follow treatment plan depending on the CIWA-ar score. This project did face a lot of resistance to start with. Many clinicians were concerned that patients could potentially be over or under dosed depending on who was doing the assessment, others felt that assessing for signs of alcohol withdrawal on a regular basis would take up to much time and others felt that introducing another assessment tool with paper work was a bad idea. To overcome resistance many change management tools were used. However most importantly was education. A teaching schedule was introduced to teach front-line staff on how to assess using the CIWA-ar score and the ICP as well as the research base for its implementation. Ensuring staff were aware this change was evidence-based and desperately needed overcame a lot of the resistance. However once the change had been implemented and comparisons could be made pre and post change was the best way to ensure the change became the norm.The only costs the project incurred was the cost to print the ICPs.

Key findings

To monitor progress a post-intervention audit was completed. Post interventions audit revealed a consistent approach to detoxification with a significant decrease in bed days used for this group of patients when using the ICP; An average of 2.48 days compared with 6.36 days before its introduction (p=0.001). There was a reduction in the average amount of Chlordiazepoxide used to complete a detox (167.2mg compared with 563.1mg before the ICP) (p value 0.001). It was clear that the implementation of NICE guidance was having a benefit on patient care by decreasing the amount of medication needed; productivity was improved with faster detox periods and staff satisfaction improved due to positive results. All the results found have the potential to save money, less bed stays and less medication. The results exceeded expectations; however it was clear continual audits were required to ensure compliance and longevity of the project.

Key learning points

- Be prepared to meet with resistance do not take this personal.
- Keep focused and determined.
- Utilise education and key stakeholders expertise.
- Continually assess the project to detect progress or setbacks.
- Utilise change management theories and practice.
- Be prepared before trying to implement.
- Changing practice will take time.
- The introduction of an ICP is a good way to keep all work together and easy to follow.

Contact details

Jay Murdoch
Lead Nurse for Alcohol
Pennine Acute Trust

Secondary care
Is the example industry-sponsored in any way?