Journal article
Implementation of a Phenobarbital-based Pathway for Severe Alcohol Withdrawal A Mixed-Method Study
ANNALS OF THE AMERICAN THORACIC SOCIETY, Vol.18(10), pp.1708-1716
10/01/2021
DOI: 10.1513/AnnalsATS.202102-121OC
PMID: 33945771
Abstract
Rationale: Several institutions have implemented phenobarbital-based pathways for the treatment of alcohol withdrawal syndrome (AWS). However, little is known about the care processes, effectiveness, and safety of phenobarbital-based pathways for intensive care unit (ICU) patients.
Objectives: To examine clinician acceptability and feasibility and patient outcomes after the implementation of a phenobarbital-based pathway for medical ICU (MICU) patients with severe AWS.
Methods: We conducted a mixed-method study of a qualityimprovement intervention designed to improve the workflow without deleterious effects on outcomes. We used semistructured, qualitative interviews and surveys of clinicians to assess the acceptability and feasibility of the phenobarbital-based pathway and a previous benzodiazepine-based pathway. We used a noninferiority interruptedtime-series analysis to compare mechanical ventilation rates before and after implementation among MICU patients within an urban safety-net hospital who were admitted with severe alcohol withdrawal. We explored several secondary outcomes, including physical restraint use and hospital length of stay.
Results: Four themes related to clinician acceptability and feasibility of the phenobarbital-based pathway emerged: 1) designing a pathway that balanced standardization with clinical judgment promoted acceptability, 2) pathway simplicity promoted feasibility, 3) implementing pathway-driven care streamlined the workflow, and 4) ad hoc implementation strategies facilitated new pathway uptake. Two hundred thirty-three and 252 patients were initiated on the benzodiazepine- and phenobarbital-based pathways, respectively. The rate of mechanical ventilation decreased from 17.1% to 12.9% after implementation of the phenobarbital-based pathway, and an adjusted mean difference of 24.9% (95% upper confidence interval [CI]: 0.7%) corresponding to relative change in the 95% upper limit of 4%, which was below the a priori noninferiority margin, was shown. After implementation, use of physical restraints decreased from 51.6% to 32.4% (mean difference, 218.0%; 95% CI: 226.4% to 29.7%), and the hospital length of stay was shorter (8.6-6.8 d; mean difference, 21.8 d; 95% CI: 23.4 to 20.2 d).
Conclusions: Clinicians believed that the phenobarbital-based pathway was more efficient and simpler to use, and patient mechanical ventilation rates were noninferior compared with the previous benzodiazepine-based pathway for the treatment of severe AWS.
Details
- Title: Subtitle
- Implementation of a Phenobarbital-based Pathway for Severe Alcohol Withdrawal A Mixed-Method Study
- Creators
- Nicholas A. Bosch - Boston UniversityErika L. Crable - Boston UniversityKimberly A. Ackerbauer - Boston Med Ctr, Dept Pharm, Boston, MA USAKristopher Clark - Boston Medical CenterMari-Lynn Drainoni - Boston UniversityValerie Grim - Boston UniversityMichael H. Ieong - Boston UniversityAllan J. Walkey - Boston UniversityJaime Murphy - National Patient Safety Foundation
- Resource Type
- Journal article
- Publication Details
- ANNALS OF THE AMERICAN THORACIC SOCIETY, Vol.18(10), pp.1708-1716
- Publisher
- Amer Thoracic Soc
- DOI
- 10.1513/AnnalsATS.202102-121OC
- PMID
- 33945771
- ISSN
- 1546-3222
- eISSN
- 2325-6621
- Number of pages
- 9
- Grant note
- Evans Center for Implementation and Improvement Sciences, School of Medicine, Boston University, Boston, Massachusetts
- Language
- English
- Date published
- 10/01/2021
- Academic Unit
- Internal Medicine
- Record Identifier
- 9984694746202771
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