Muzyk Andrew J, Rogers Rachel E, Dighe Gary, Hartung Jessica, Musser Robert C, Stillwagon Mary J, Rivelli Sarah
MUZYK: Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC; Department of Pharmacy, Duke University Hospital, Durham, NC; and Department of Psychiatry and Behavioral Sciences, Duke University Health System, Durham, NC ROGERS: Department of Pharmacy, Duke University Hospital, Durham, NC DIGHE: Department of Pharmacy, Ohio State University-Ohio Riverside Hospital, Columbus, OH HARTUNG: Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC MUSSER: Department of Medicine, Duke University Health System, Durham, NC STILLWAGON: Department of Nursing, Duke University Health System, Durham, NC RIVELLI: Department of Psychiatry and Behavioral Sciences and Department of Medicine, Duke University Health System, Durham, NC.
J Psychiatr Pract. 2017 May;23(3):233-241. doi: 10.1097/PRA.0000000000000229.
To determine if the implementation of a hospital-specific alcohol withdrawal treatment pathway used in a medical-surgical patient population decreased hospital length of stay (LOS) compared with the standard of care.
This retrospective observational study, conducted in a large academic tertiary care hospital, involved 582 subjects who met criteria for study inclusion, with 275 subjects in the 2010 cohort and 307 in the 2012 cohort. The Alcohol Withdrawal Project Team was formed with the goal of creating a standardized approach to the recognition and treatment of alcohol withdrawal at Duke University Hospital. The group created a computerized physician order entry alcohol withdrawal treatment pathway with 4 possible treatment paths chosen on the basis of current withdrawal symptoms, vital signs, and alcohol withdrawal history. The 4 treatment paths are 1 prophylaxis; 2 mild-to-moderate withdrawal; 3 moderate-to-severe withdrawal, and 4 severe withdrawal/alcohol withdrawal delirium. Each treatment path corresponds to a different lorazepam dose and dose schedule and symptom assessment. This pathway was implemented in the hospital at the end of 2011.
Using a Cox proportional hazards model and adjusting for covariates, there was a 1 day [95% confidence interval (CI), 1-2 d] reduction in median hospital LOS between the 2010 and 2012 cohorts, 5 versus 4 days, respectively. The average ratio in hospital LOS between the 2 cohorts was 1.25 (95% CI, 1.25-1.67). The CI was estimated by bootstrapping and indicated a significantly longer LOS in the 2010 cohort compared with the 2012 cohort. Nonsignificant changes were found in the proportion of subjects admitted to the intensive care unit (24% in 2010 vs. 29.3% in 2012), LOS in the intensive care unit (7.1±8 d in 2010 vs. 5.6±6.9 d in 2012), and proportion of patients discharged with a diagnosis of delirium tremens (17.8% in 2010 vs. 15.3% in 2012).
This study demonstrates the successful implementation of an alcohol withdrawal treatment pathway in a medical-surgical population hospitalized in a large tertiary care facility with significant impact on hospital LOS.
确定在外科手术患者群体中实施特定医院酒精戒断治疗方案与标准治疗相比是否能缩短住院时间（LOS）。
这项回顾性观察研究在一家大型学术三级护理医院进行，纳入了582名符合研究纳入标准的受试者，其中2010年队列有275名受试者，2012年队列有307名受试者。成立了酒精戒断项目团队，目标是创建一种标准化方法，用于杜克大学医院对酒精戒断的识别和治疗。该团队创建了一个计算机化医嘱录入酒精戒断治疗方案，根据当前戒断症状、生命体征和酒精戒断史选择4种可能的治疗路径。这4种治疗路径分别是：1. 预防；2. 轻度至中度戒断；3. 中度至重度戒断；4. 重度戒断/酒精戒断谵妄。每种治疗路径对应不同的劳拉西泮剂量、给药方案和症状评估。该方案于2011年底在医院实施。
使用Cox比例风险模型并对协变量进行调整后，2010年队列和2012年队列的中位住院LOS分别为5天和4天，缩短了1天[95%置信区间（CI），1 - 2天]。两个队列的住院LOS平均比值为1.25（95%CI，1.25 - 1.67）。通过自抽样估计CI，表明2010年队列的LOS显著长于2012年队列。在入住重症监护病房的受试者比例（2010年为24%，2012年为29.3%）、重症监护病房的LOS（2010年为7.1±8天，2012年为5.6±6.9天）以及出院诊断为震颤谵妄的患者比例（2010年为17.8%，2012年为15.3%）方面未发现显著变化。
本研究表明，在一家大型三级护理机构住院的外科手术患者群体中成功实施了酒精戒断治疗方案，对住院LOS有显著影响。
