Graduation Semester and Year

Summer 2024

Language

English

Document Type

Dissertation

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Kirsten Drake

Abstract

Background: In the United States, 52.8% of Americans aged 18 and older consume alcohol, with 29.5 million suffering from alcohol use disorder (AUD). In Los Angeles, 69.8% of Angelinos aged 12 and older suffer from AUD, and 33% of annual arrests are due to alcohol and other drugs. Alcohol withdrawal syndrome (AWS) develops after abrupt cessation of heavy drinking and is a common occurrence among incarcerated people when newly arrested, resulting in $1.3 billion in healthcare costs. Management of AWS using a fixed-dose therapy of benzodiazepines will improve the utilization of healthcare services in the correctional setting.

Objectives: The project aimed to create a guideline for managing alcohol withdrawal syndrome using a fixed-dose therapy of benzodiazepines that supported current graded evidence-based recommendations and stakeholders’ ratings for these recommendations.

Design, Setting, and Population: The project used a mixed-method review of different evidence-based studies that were summarized in an evidence table. The setting was a Southern California jail. The population of interest was healthcare workers—registered nurses, nurse practitioners, physician assistants, clinical pharmacists, and medical doctors.

Methods: A literature review of various studies was conducted to develop eight evidence-based recommendations that were graded and rated by stakeholders to develop a clinical guideline for managing AWS: (1) Assess patients for signs and symptoms of alcohol withdrawal using the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) upon arrival to the jail; (2) Implement a standardized fixed-dose protocol with benzodiazepine therapy based on the severity of alcohol withdrawal symptoms; (3) Benzodiazepines are the preferred medications for patients experiencing alcohol withdrawal symptoms; (4) Patients presenting with mild alcohol withdrawal symptoms and having pre-existing risk factors for complicated withdrawals should be treated with a fixed-dose schedule of benzodiazepines; (5) Provide supportive care to patients by educating them on the course of withdrawals, consuming multivitamins, folic acid, and thiamine, and instructing patients on how to maintain low-stimulation environments; (6) Assess factors associated with an increased risk for complicated withdrawals, including a history of alcohol withdrawal delirium (DTs), alcohol withdrawal seizures, and a long duration of regular and heavy alcohol consumption; (7) Implement strategies to reduce the risk of benzodiazepine misuse, diversion, and dependence through patient education, limiting the duration of benzodiazepine therapy, and considering other alternatives; (8) Patients successfully treated for AWS should be offered a referral to a long-term treatment program to maintain abstinence and adjunctive use of an FDA-approved pharmacotherapy.

Results: After stakeholders rated the recommendations using a four-point Likert scale (rating 1-4), the mean scores ranged from 3.50 to 3.80. The data was analyzed using SPSS, and Friedman’s Two-Way Analysis of Variance (ANOVA) by Ranks was used to test for differences in the stakeholders’ ratings. The hypothesis test summary showed no significant statistical differences in the stakeholders’ ratings of the recommendations (p-value of 0.652, significance level of .05). All eight proposed recommendations achieved a mean score greater than 3 and were included in the final guideline development.

Conclusions: Creating an updated guideline for the management of alcohol withdrawal syndrome using a fixed-dose therapy of benzodiazepine will help correctional healthcare workers better utilize healthcare services, as evidenced by reduced cumulative benzodiazepine use, hospital length of stay, and readmission rates.

Keywords: Alcohol withdrawal syndrome, fixed-dose therapy, benzodiazepines.

Keywords

Alcohol withdrawal syndrome, fixed-dose therapy, benzodiazepines.

Disciplines

Family Practice Nursing | Mental Disorders | Psychiatric and Mental Health Nursing | Psychiatry

Comments

I would like to thank God for this once-in-a-lifetime opportunity and for seeing me through this program. To my family and friends, I say “thank you” for your unwavering support throughout this challenging journey. To my children, I am very grateful for your love and support and sorry for the days you felt ignored because I was working on my assignments. To my dad (in heaven) and my mom, you are the rock I can lean on anytime, and this degree is for you both. A special “thank you” to my faculty advisor, Dr. Drake, and Dr. Kao, the statistician, for your assistance.

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