A Medical Audit of Acute Alcoholism and Chronic Alcoholism James W. West, M.D.
A medical audit for acute alcoholism was done in a large private general hospital where the cases are admitted to and treated on the general medical service. Another medical audit was done for chronic alcoholism for patients admitted to an alcoholism rehabilitation unit in a large general hospital in a teaching center.
A
MEDICAL A U D I T is an outcomeoriented evaluation of the quality of patient care. When measured against explicit predictions of optimally achievable outcomes, the differences found (if any) will disclose potential problems that can be subjected to peer review. The essential characteristics* of an acceptable medical audit should include the following steps: (1) The establishment of valid criteria that permit objective review of the quality of care given to all patients and that provide validation for the diagnosis and justification for admission to the hospital or other institution. These criteria should include a statement of expected patient outcomes and also define acceptable processes of patient care and management. (2) The measurement of actual practice against the criteria, which will produce reliable data. (3) The analysis of measurement results by peers. (4) The correction of the problems identified. (5) Follow-up action to insure correction of the problems (this is immediate if the problem is life-threatening); improvement of care is documented by a repeat audit. ( 6 ) Report the results of the audit in general terms, with specific recommendations to the governing bodies and to the chief of the medical staff. A medical audit for acute alcoholism was done in a large private general hospital where the cases are admitted to and treated on the general medical service. Another medical audit was done for chronic alcoholism for patients admitted to an alcoholism rehabilitation unit in a large general hospital in a teaching center. In both audits, the criteria were developed by a group of physicians, nurses, and other personnel Alcoholism: Clinicaland Experimental Research, Vol. 2.
involved in the care of the alcoholic patient. As in all audits, the criteria were developed for three categories: ( I ) justification for medical intervention, which must include the essentials for making the diagnosis of acute or chronic alcoholism; (2) the patient outcome; and (3) nonspecific indicators, which include complications and their correct critical management. The medical audit for acute alcoholism (Table 1 ) includes, as justification for the diagnosis of acute alcoholism, the measurable symptoms and signs of psychomotor agitation, tremors, hallucinations, delirium, o r seizure activity. Under instructions for the Audit Committee technician who processes the charts by comparing actual performance to criteria, these symptoms are described in detail. The justification for admission to the hospital for acute alcoholism includes criteria of acute intoxication coupled with an injury or concomitant medical disorder (such as fever, diabetes, bleeding) or hallucinations, delirium, or seizure disorder. The withdrawal states were classified according to stages I through IV and were described in detail in the instruction column of the audit sheet for the audit technician. Primarily, this justification for admission to the hospital reduced the number of patients suffering from acute alcoholism who were admitted to the hospital to those whose acute alcoholism was accompanied by complications. The large majority of patients who present to the general hospital with acute alcoholism suffer from uncomplicated intoxication or stage I withdrawal syndrome, i.e., psychomotor agitation and tremulousness. These patients can be detoxified successfully as outpatients3or are referred directly to rehabilitation centers. The category of justification in the audit for
From rhe Department of Psychiatry, Rush-Presbyterian-St. Luke's Medical Center and Alcoholism Services and the Division of Surgery, Litrle Company of Mary Hospital, Evergreen Park, Ill. Reprint requests should be addressed to James W.West, M . D . . Lirtle Company of Mary Hospiral. 2800 West 95 Street. Evergreen Park, Ill. 60642. o 1978 by Grune & Straiton. Inc. 0145-6008/78/0203-0039%01.00/0
No. 3 (July). 1978
287
JAMES W. WEST
288
Table I.Audit Criteria for Acute Alcoholism Critena Number
Standard Elemenn
100%
1. la1 Psychomotor agitation and
X
0%
Exceptions
Instructions and Definitions for Data Ret~ieval
Diagmis Psychomotor agitation
-
shakes
tremom or Acute intoxication * blood alcohol
Ibl Hallucinations or (cl Delirium or
>
150 mg/100ml
Id) Seizures Admission
2. (a1 Acute intoxication M stage I
X
2 IAl Admiamon criteria. if wat noted on ER record. may be found on progress notes. history and
with other diceass w injury or Ibl Stage I ) . 111.01 IV acute withdrawal syndrome or
phqsual. discharge summary
lcl Acute intoxication with history ofstage 11. II1.w N withdrawal symptoms
Stage I
--
psychomotor agitation tremulousness tachycardia (pulse above 901 sweating hypertension (above 1501-I
Stage II
above with hallucinations Stage Ill above with delirium Idisonmtrtionl Stage IV = above with seuures or history of seizures Either the stage number or the symptoms may be recorded
Above to be noted on EWAC record I-IV and acute intoxication 3 Sedativesand
Treatment-Stagw
4 Therapy 5 Noreswaints 6 Anticonvulsants ifstage IV
Sedatives include Librium. thorazine. Valium. haMol
6 IAI Restreints in stage 111 ifpatient is threat to self or others
Therapy lindindual counsalling. group therapy. Alcoholics Anonymous meeting1cntsria met if any of the above is ordered end nurses' notas document participation
Discharge status
7 Ambulatory and 8 All psychoactive drugs lradativesl discontiwed and 9 Onsdddia 10 Mortaliw 1 1 Length of stay 2-1 0 days 12 Other i v if dahflratim 16not documented
Complications 13 Dehydration
14 Hvperpyrexia 15 Renal shutdown 18 Esophageal hemorrhage
11 IA) Complications below
CrRical prevantwa and responsive management I v fluid replacement Hypotherrnia machine fluids Fluds steroids hywtharmia machine Blood replacement Sengstaken tube
--
Dehydration as documented in record Hyperpyrexia temparature > 103' Renal shutdown no urlnary output Gastric hemwrhage = any vomiting of Mood
portocaval shunt
17 Gastric hemwrhage 18. Pancreatitis
Blood replacement i f hematcurit below 30 Antibiotics, pain medication
acute alcoholism also includes fundamentals of medical management, including sedation and involvement in psychosocial therapy during the hospital stay, plus a firm follow-up referral to therapy after discharge. The category of patient outcome includes a discharge status of ambulatory, with all psychoactive addicting drugs discontinued, with referral to the outpatient service or a rehabilitation unit. The length of stay was established at 2-10 days. Mortality in all audits is established at O%, so that each death case is brought to review. In this series there were no deaths, but in the approximately 1700 cases of acute alcoholism admitted to this general hospital in the past 3% yr, there have been approximately 40 deaths, all of which have been reviewed, and in most of which autopsies have been performed.
Under nonspecific indicators, as the third category of criteria, the common complications are listed and their critical management is described. These include dehydration, hyperpyrexia, renal shutdown, gastrointestinal hemorrhage, and pancreatitis. The audit summary on acute alcoholism included 100 consecutive case records (Table 2). There were seven physicians in the study. It was found that 96% of the criteria for diagnosis were met, and 4% of admissions revealed poor documentation of measurable signs of acute alcoholism. Treatment criteria were met, but length of stay was unjustifiably long in several cases in which return of laboratory reports was delayed. The critical management of complications uncovered a problem consisting of the inappropriate use of i.v. fluids in acute withdrawal
MEDICAL AUDIT
OF ACUTE A N D CHRONIC ALCOHOLISM
289
Table 2. Medical Audit Summary for Acute Alcoholism Medical Audit Audn Study Topic Alcoholism-Withdrawal
Syndrome
Date February 1976 No Nursing Units en Study Total
No Records Raviewad lo0 No Physicians in Study 7
Discharge
Actual Practice Summaw Audit Criteria
No
?&
ProblamdActtms
Diagnosis 1
la1 Psychomotor agltamn and tremors or
96
96
98
98
Ibl Delirium or
Poor documentatlon of signs and symptoms of withdrawal syndrome To have refresher for ER and OP staff concerntng abave
Icl Seuures Admission
2 la) Acute lnloiicatlan or stage I with other diseare or injury or lbl Acute intoxication with h m q of stage II 111
N
Committee chairman to spank to attending physician re uniustthed adrnlssions. overstays. I v with no dehydration documented
withdrawal syndrome or
Review standing orders for alcohol withdrawal patients with
Icl Stage I1 Ill IV withdrawal syndrome
nur5,ng staff
Treatmsnt
3 Sedatives 4 Therapy 5 No restraints 6 Antfconvulsants 11stage 111
100
lo0 99 3
100 100 99
dehydration documentation
100
Sieberl be given authority todocument patient parlmpatlon
ER staff to be instructed re routine I v with absence of Change in therapy critena Committee fecommends that Ken in therapy on progress notes
Discharge
E
8
d
7 Ambulatory 8 All psychoactive drugs discontinued 9 Solid diet 10 Mortality 11 Length of stay 2- 10 days 12 Other-) v 11dehyration not documented
100 100 100 0
100 100 100 0
98
98
12
12
Clarification of discharge criteria All Mldative.tranquili2ers 11
e , Valium. Librum. Miltownl and sedatiw-hypnotics
11
e . Dalmane. chloral hydrate. barbiturates1 to be discon-
tinued Ithis doesn't include major lranqu~lizersl
Complications
5
13 Dehydration
6
6
14 Hyperpyrexla 15 Renal shutdown
D
0 0
16 Esophageal hemorrhage 17 Gastric hemorrhage
0
18 Pancreatitis
1
0
3
states. This occurred in 12% of cases, and in all instances, the fluids were ordered by the Emergency Room personnel. The action follow-up consisted in a review of diagnostic criteria for admission to the hospital with Emergency Room physicians and one attending physician who did not properly document his findings. Several physicians were spoken to about unnecessary overstays, and for one patient, restraints were used unnecessarily. The entire treatment of acute alcoholism was reviewed with the Nursing Division including all the head and staff nurses. This review will take place every 4 mo. The Emergency Room personnel were instructed about the use of i.v. fluids in acute alcoholism, the process of triage was reviewed, and the review of triage and treatment scheduled regularly. The audit was reported to and acknowledged by the governing body and executive officers and distributed to the entire medical staff.
Memo to EEG dept re 1 week delay between order foi EEG and results recaived 15270-2377
0 3 1
The audit of acute alcoholism in this hospital is the responsibility of the Department of Internal Medicine. It will be repeated in 18 mo. The audit for chronic alcoholism was done in another hospital, a component of a large teaching center. This was designed by members of the Department of Psychiatry with input from the nursing staff, alcoholism therapists, and medical record personnel. The site for treatment of the patient with chronic alcoholism is a rehabilitation unit. In the audit for chronic alcoholism (Table 3), the justification for the diagnosis includes withdrawal signs, which are described, and/or a blood alcohol above 300 mg/ I 0 0 ml, a history of memory blanks, and/or drinking in spite of strong medical or social contraindications, or habitual excessive drinking (this is described). Justification for admission includes an expressed desire for treatment for permanent abstinence; assaultiveness associated with
JAMES W. WEST
2 90
Table 3. Audit Criteria for Chronic Alcoholism standard Criteria Number
Elements
Diagnosis 1 la) (b) icl (dl
(el
100%
0%
Instructions and Oefinitrons lor Data Retneval
Exceptions
1 la) Shakes. tremors. confusion. disonen-
WlMrswal signs or Blood alcohol level above 300 m y 100 ml 01 Memory blanks 01 lntoxiution despite medical contraindications 01 Habitual excessive drinking
tatwn. hallucinations. delusions. 5aIZUIWS (c1 Alcoholic blackouts 181
5 5
'E,
!
year. coordination and speech imDaired
Admission
2 Id1 Pancreatilis. hepatitis. cirrhosis.
2 la1 Desires treatment lor permanent abstinencs or
'
(bl Asseultiveness associated with drinking or icl Outpatient treatment has tailed or id) Acute exacerbation of alcohol-related medical illness
Discharw s1atu6 3 Has vitamin supplements to take home 4 All minor tranquilizers discontinued
;
g 6
Drinks heavily more than lour limes a
X X
5 All addictive drugs discontinued
X
6 After care plan including referral established
X
7 Famolylsignnlcantothers advised of care plan 8 Mortality 9 Length 01 stay--7 days minimum to 28 days maximum on alcohol unit
X
gastrttis
(3-71 (A1 Patiant drinking while on premisas. IBI AMA discharge
5 Antidepressants and major t r a n ~ ~ i l l i ~ ~ i ~
ICI death
are acceptable 6 Including sedatives barbiturates. chloral hydrafe and Q u l l u d e
4 X
Other 10 In house psychislric consultation lor
g 5
p
1I
patients not on alcohol unit TBskin test
12 13 14 15
EKG LIVW funcliontest CEC chest x-ray
Complications
16 Oversedation with or w l t h o ~ tcoma
X
Cnttcal prevenlive and responsive management 16 (A1 All sedatives stopped and
IBI Patient's vital signs mon-
b
itomd at least every
2 hr
drinking; outpatient treatment failure; acute exacerbation of an alcohol-related medical illness. Under outcome criteria, the discharge status includes discontinuation of sedatives and minor tranquilizers and an after-care plan explained to and including family members. The mortality was established as 0%. The length of stay consisted of 7 days minimum to 28 days maximum. The nonspecific indicator criteria included complications of oversedating and some routine diagnostic procedures. The audit summary for chronic alcoholism included 100 consecutive cases (Table 4). There were 20 physicians in the study. The diagnostic criteria were met in 100% of cases. In one case, the admission to the unit was unjustified. The outcome category showed that in the discharge status of three patients, the rationale for
continued use of tranquilizers following discharge was not documented. In several cases, there was no documentation that the family had been informed of the follow-up care plan. The action follow-up included conferences with physicians regarding documentation of criteria for admission, documentation of rationale for discharge with psychoactive medication, and staff instruction regarding the review of the after-care treatment plan with the family. It was decided to repeat the audit in 1 yr, with special monitoring of the variations noted. As with all audits, this was reported and acknowledged, and distributed to the appropriate bodies. In conclusion, the medical audit4has, in addition to the assessment of quality of care, the dividend of a profound educational experience for the staff. And finally, the medical audit treats alcoholism with the respect that a highly fatal illness demands.
MEDICAL AUDIT OF ACUTE A N D CHRONIC ALCOHOLISM
291
Table 4. Medical Audit Summary for Chronic Alcoholism Medical Audit
Audit Study Topic: Chronic Alcoholism No. Records Reviewed. 100 No. Physicians in Study: 2 0
Date: October 13. 1975 No. Nursing U n i t s in Study: Total 8 Discharge: 7
Actual Practice Summary
No
%
100%
100
100
100%
99
99
(2) Counsel individual doctor on admission criteria of alcohol program
100% 100% 100% 100%
63 97
63 97
77
77
(3) Confer with Director of QAP concerning documentation of discharge meds in POMR sys tems 14) Review with individual doctors the need to document the rationale for minor tranquilizers 16 & 7) Inform nursing units of newly established discharge documentation procedure. will re-audit a selected sample in 6 mo
100%
100
100
100% 100% 100% 100% 100% 100%
97 18 87 100 100 81
97 18 87 100 100 81
0
0
Audit Criteria
C
0
Diagnosis 1 (a) (b) lcl Id) (e)
Problems/Actions
Withdrawal signs or Blood alcohol level above 300 mg/100 ml or Memory blanks or Intoxication despite medical contraindications Habitual excessive drinking
I
J 2-
[
Admission 2 la) Desires treatment for permanent abstinence or Ib) Assaultiveness associated with drinking or (c) Outpatient treatment has failed or Id1 Acute exacerbation of alcohol-related medical illness Discharge status 3 Has vitamin supplements to take home 4 All minor tranquilizersdiscontinued 5 All addiclive drugs discontinued 6 After care plan including referral, established and patient advised 7 Family/significant others advised of care plan 8 Mortality
0
? o
Length of stay 9 7 days minimum to 28 days maximum on alcohol unit 10 In-house consult for patients not on alcohol unit 11 T8 skin test 12 EKG 13 Liver function test 14 CBC 15 Chest x-ray
0
-
Complications 16 Oversedationwith or without coma
0%
(12 & 15) Advise the doctor responsible for the medical work-up of alcoholism patients that EKGs and chest x-rays are not being performed on all patients and that these are necessary diagnostic procedures
REFERENCES I . Jacobs CM: PEP for the Uninitiated. QRB, Dec 1975, PP 3-5 2. Essential Characteristics of an Acceptable Patient Care Evaluation Procedure-Audit Action Letter. February 1, 1977
3. Feldman DJ, et al: Outpatient alcohol detoxification: Initial findings on 564 patients. Am J Psychiatry 132:4, 1974 4. West JW: Thegeneral hospital as a primary setting for the treatment of alcoholism. Paper presented before the NCA meeting, Washington DC, 1976
A medical audit for acute alcoholism was done in a large private general hospital where the cases are admitted to and treated on the general medical service. Another medical audit was done for chronic alcoholism for patients admitted to an alcoholism rehabilitation unit in a large general hospital in a teaching center.
A
MEDICAL A U D I T is an outcomeoriented evaluation of the quality of patient care. When measured against explicit predictions of optimally achievable outcomes, the differences found (if any) will disclose potential problems that can be subjected to peer review. The essential characteristics* of an acceptable medical audit should include the following steps: (1) The establishment of valid criteria that permit objective review of the quality of care given to all patients and that provide validation for the diagnosis and justification for admission to the hospital or other institution. These criteria should include a statement of expected patient outcomes and also define acceptable processes of patient care and management. (2) The measurement of actual practice against the criteria, which will produce reliable data. (3) The analysis of measurement results by peers. (4) The correction of the problems identified. (5) Follow-up action to insure correction of the problems (this is immediate if the problem is life-threatening); improvement of care is documented by a repeat audit. ( 6 ) Report the results of the audit in general terms, with specific recommendations to the governing bodies and to the chief of the medical staff. A medical audit for acute alcoholism was done in a large private general hospital where the cases are admitted to and treated on the general medical service. Another medical audit was done for chronic alcoholism for patients admitted to an alcoholism rehabilitation unit in a large general hospital in a teaching center. In both audits, the criteria were developed by a group of physicians, nurses, and other personnel Alcoholism: Clinicaland Experimental Research, Vol. 2.
involved in the care of the alcoholic patient. As in all audits, the criteria were developed for three categories: ( I ) justification for medical intervention, which must include the essentials for making the diagnosis of acute or chronic alcoholism; (2) the patient outcome; and (3) nonspecific indicators, which include complications and their correct critical management. The medical audit for acute alcoholism (Table 1 ) includes, as justification for the diagnosis of acute alcoholism, the measurable symptoms and signs of psychomotor agitation, tremors, hallucinations, delirium, o r seizure activity. Under instructions for the Audit Committee technician who processes the charts by comparing actual performance to criteria, these symptoms are described in detail. The justification for admission to the hospital for acute alcoholism includes criteria of acute intoxication coupled with an injury or concomitant medical disorder (such as fever, diabetes, bleeding) or hallucinations, delirium, or seizure disorder. The withdrawal states were classified according to stages I through IV and were described in detail in the instruction column of the audit sheet for the audit technician. Primarily, this justification for admission to the hospital reduced the number of patients suffering from acute alcoholism who were admitted to the hospital to those whose acute alcoholism was accompanied by complications. The large majority of patients who present to the general hospital with acute alcoholism suffer from uncomplicated intoxication or stage I withdrawal syndrome, i.e., psychomotor agitation and tremulousness. These patients can be detoxified successfully as outpatients3or are referred directly to rehabilitation centers. The category of justification in the audit for
From rhe Department of Psychiatry, Rush-Presbyterian-St. Luke's Medical Center and Alcoholism Services and the Division of Surgery, Litrle Company of Mary Hospital, Evergreen Park, Ill. Reprint requests should be addressed to James W.West, M . D . . Lirtle Company of Mary Hospiral. 2800 West 95 Street. Evergreen Park, Ill. 60642. o 1978 by Grune & Straiton. Inc. 0145-6008/78/0203-0039%01.00/0
No. 3 (July). 1978
287
JAMES W. WEST
288
Table I.Audit Criteria for Acute Alcoholism Critena Number
Standard Elemenn
100%
1. la1 Psychomotor agitation and
X
0%
Exceptions
Instructions and Definitions for Data Ret~ieval
Diagmis Psychomotor agitation
-
shakes
tremom or Acute intoxication * blood alcohol
Ibl Hallucinations or (cl Delirium or
>
150 mg/100ml
Id) Seizures Admission
2. (a1 Acute intoxication M stage I
X
2 IAl Admiamon criteria. if wat noted on ER record. may be found on progress notes. history and
with other diceass w injury or Ibl Stage I ) . 111.01 IV acute withdrawal syndrome or
phqsual. discharge summary
lcl Acute intoxication with history ofstage 11. II1.w N withdrawal symptoms
Stage I
--
psychomotor agitation tremulousness tachycardia (pulse above 901 sweating hypertension (above 1501-I
Stage II
above with hallucinations Stage Ill above with delirium Idisonmtrtionl Stage IV = above with seuures or history of seizures Either the stage number or the symptoms may be recorded
Above to be noted on EWAC record I-IV and acute intoxication 3 Sedativesand
Treatment-Stagw
4 Therapy 5 Noreswaints 6 Anticonvulsants ifstage IV
Sedatives include Librium. thorazine. Valium. haMol
6 IAI Restreints in stage 111 ifpatient is threat to self or others
Therapy lindindual counsalling. group therapy. Alcoholics Anonymous meeting1cntsria met if any of the above is ordered end nurses' notas document participation
Discharge status
7 Ambulatory and 8 All psychoactive drugs lradativesl discontiwed and 9 Onsdddia 10 Mortaliw 1 1 Length of stay 2-1 0 days 12 Other i v if dahflratim 16not documented
Complications 13 Dehydration
14 Hvperpyrexia 15 Renal shutdown 18 Esophageal hemorrhage
11 IA) Complications below
CrRical prevantwa and responsive management I v fluid replacement Hypotherrnia machine fluids Fluds steroids hywtharmia machine Blood replacement Sengstaken tube
--
Dehydration as documented in record Hyperpyrexia temparature > 103' Renal shutdown no urlnary output Gastric hemwrhage = any vomiting of Mood
portocaval shunt
17 Gastric hemwrhage 18. Pancreatitis
Blood replacement i f hematcurit below 30 Antibiotics, pain medication
acute alcoholism also includes fundamentals of medical management, including sedation and involvement in psychosocial therapy during the hospital stay, plus a firm follow-up referral to therapy after discharge. The category of patient outcome includes a discharge status of ambulatory, with all psychoactive addicting drugs discontinued, with referral to the outpatient service or a rehabilitation unit. The length of stay was established at 2-10 days. Mortality in all audits is established at O%, so that each death case is brought to review. In this series there were no deaths, but in the approximately 1700 cases of acute alcoholism admitted to this general hospital in the past 3% yr, there have been approximately 40 deaths, all of which have been reviewed, and in most of which autopsies have been performed.
Under nonspecific indicators, as the third category of criteria, the common complications are listed and their critical management is described. These include dehydration, hyperpyrexia, renal shutdown, gastrointestinal hemorrhage, and pancreatitis. The audit summary on acute alcoholism included 100 consecutive case records (Table 2). There were seven physicians in the study. It was found that 96% of the criteria for diagnosis were met, and 4% of admissions revealed poor documentation of measurable signs of acute alcoholism. Treatment criteria were met, but length of stay was unjustifiably long in several cases in which return of laboratory reports was delayed. The critical management of complications uncovered a problem consisting of the inappropriate use of i.v. fluids in acute withdrawal
MEDICAL AUDIT
OF ACUTE A N D CHRONIC ALCOHOLISM
289
Table 2. Medical Audit Summary for Acute Alcoholism Medical Audit Audn Study Topic Alcoholism-Withdrawal
Syndrome
Date February 1976 No Nursing Units en Study Total
No Records Raviewad lo0 No Physicians in Study 7
Discharge
Actual Practice Summaw Audit Criteria
No
?&
ProblamdActtms
Diagnosis 1
la1 Psychomotor agltamn and tremors or
96
96
98
98
Ibl Delirium or
Poor documentatlon of signs and symptoms of withdrawal syndrome To have refresher for ER and OP staff concerntng abave
Icl Seuures Admission
2 la) Acute lnloiicatlan or stage I with other diseare or injury or lbl Acute intoxication with h m q of stage II 111
N
Committee chairman to spank to attending physician re uniustthed adrnlssions. overstays. I v with no dehydration documented
withdrawal syndrome or
Review standing orders for alcohol withdrawal patients with
Icl Stage I1 Ill IV withdrawal syndrome
nur5,ng staff
Treatmsnt
3 Sedatives 4 Therapy 5 No restraints 6 Antfconvulsants 11stage 111
100
lo0 99 3
100 100 99
dehydration documentation
100
Sieberl be given authority todocument patient parlmpatlon
ER staff to be instructed re routine I v with absence of Change in therapy critena Committee fecommends that Ken in therapy on progress notes
Discharge
E
8
d
7 Ambulatory 8 All psychoactive drugs discontinued 9 Solid diet 10 Mortality 11 Length of stay 2- 10 days 12 Other-) v 11dehyration not documented
100 100 100 0
100 100 100 0
98
98
12
12
Clarification of discharge criteria All Mldative.tranquili2ers 11
e , Valium. Librum. Miltownl and sedatiw-hypnotics
11
e . Dalmane. chloral hydrate. barbiturates1 to be discon-
tinued Ithis doesn't include major lranqu~lizersl
Complications
5
13 Dehydration
6
6
14 Hyperpyrexla 15 Renal shutdown
D
0 0
16 Esophageal hemorrhage 17 Gastric hemorrhage
0
18 Pancreatitis
1
0
3
states. This occurred in 12% of cases, and in all instances, the fluids were ordered by the Emergency Room personnel. The action follow-up consisted in a review of diagnostic criteria for admission to the hospital with Emergency Room physicians and one attending physician who did not properly document his findings. Several physicians were spoken to about unnecessary overstays, and for one patient, restraints were used unnecessarily. The entire treatment of acute alcoholism was reviewed with the Nursing Division including all the head and staff nurses. This review will take place every 4 mo. The Emergency Room personnel were instructed about the use of i.v. fluids in acute alcoholism, the process of triage was reviewed, and the review of triage and treatment scheduled regularly. The audit was reported to and acknowledged by the governing body and executive officers and distributed to the entire medical staff.
Memo to EEG dept re 1 week delay between order foi EEG and results recaived 15270-2377
0 3 1
The audit of acute alcoholism in this hospital is the responsibility of the Department of Internal Medicine. It will be repeated in 18 mo. The audit for chronic alcoholism was done in another hospital, a component of a large teaching center. This was designed by members of the Department of Psychiatry with input from the nursing staff, alcoholism therapists, and medical record personnel. The site for treatment of the patient with chronic alcoholism is a rehabilitation unit. In the audit for chronic alcoholism (Table 3), the justification for the diagnosis includes withdrawal signs, which are described, and/or a blood alcohol above 300 mg/ I 0 0 ml, a history of memory blanks, and/or drinking in spite of strong medical or social contraindications, or habitual excessive drinking (this is described). Justification for admission includes an expressed desire for treatment for permanent abstinence; assaultiveness associated with
JAMES W. WEST
2 90
Table 3. Audit Criteria for Chronic Alcoholism standard Criteria Number
Elements
Diagnosis 1 la) (b) icl (dl
(el
100%
0%
Instructions and Oefinitrons lor Data Retneval
Exceptions
1 la) Shakes. tremors. confusion. disonen-
WlMrswal signs or Blood alcohol level above 300 m y 100 ml 01 Memory blanks 01 lntoxiution despite medical contraindications 01 Habitual excessive drinking
tatwn. hallucinations. delusions. 5aIZUIWS (c1 Alcoholic blackouts 181
5 5
'E,
!
year. coordination and speech imDaired
Admission
2 Id1 Pancreatilis. hepatitis. cirrhosis.
2 la1 Desires treatment lor permanent abstinencs or
'
(bl Asseultiveness associated with drinking or icl Outpatient treatment has tailed or id) Acute exacerbation of alcohol-related medical illness
Discharw s1atu6 3 Has vitamin supplements to take home 4 All minor tranquilizers discontinued
;
g 6
Drinks heavily more than lour limes a
X X
5 All addictive drugs discontinued
X
6 After care plan including referral established
X
7 Famolylsignnlcantothers advised of care plan 8 Mortality 9 Length 01 stay--7 days minimum to 28 days maximum on alcohol unit
X
gastrttis
(3-71 (A1 Patiant drinking while on premisas. IBI AMA discharge
5 Antidepressants and major t r a n ~ ~ i l l i ~ ~ i ~
ICI death
are acceptable 6 Including sedatives barbiturates. chloral hydrafe and Q u l l u d e
4 X
Other 10 In house psychislric consultation lor
g 5
p
1I
patients not on alcohol unit TBskin test
12 13 14 15
EKG LIVW funcliontest CEC chest x-ray
Complications
16 Oversedation with or w l t h o ~ tcoma
X
Cnttcal prevenlive and responsive management 16 (A1 All sedatives stopped and
IBI Patient's vital signs mon-
b
itomd at least every
2 hr
drinking; outpatient treatment failure; acute exacerbation of an alcohol-related medical illness. Under outcome criteria, the discharge status includes discontinuation of sedatives and minor tranquilizers and an after-care plan explained to and including family members. The mortality was established as 0%. The length of stay consisted of 7 days minimum to 28 days maximum. The nonspecific indicator criteria included complications of oversedating and some routine diagnostic procedures. The audit summary for chronic alcoholism included 100 consecutive cases (Table 4). There were 20 physicians in the study. The diagnostic criteria were met in 100% of cases. In one case, the admission to the unit was unjustified. The outcome category showed that in the discharge status of three patients, the rationale for
continued use of tranquilizers following discharge was not documented. In several cases, there was no documentation that the family had been informed of the follow-up care plan. The action follow-up included conferences with physicians regarding documentation of criteria for admission, documentation of rationale for discharge with psychoactive medication, and staff instruction regarding the review of the after-care treatment plan with the family. It was decided to repeat the audit in 1 yr, with special monitoring of the variations noted. As with all audits, this was reported and acknowledged, and distributed to the appropriate bodies. In conclusion, the medical audit4has, in addition to the assessment of quality of care, the dividend of a profound educational experience for the staff. And finally, the medical audit treats alcoholism with the respect that a highly fatal illness demands.
MEDICAL AUDIT OF ACUTE A N D CHRONIC ALCOHOLISM
291
Table 4. Medical Audit Summary for Chronic Alcoholism Medical Audit
Audit Study Topic: Chronic Alcoholism No. Records Reviewed. 100 No. Physicians in Study: 2 0
Date: October 13. 1975 No. Nursing U n i t s in Study: Total 8 Discharge: 7
Actual Practice Summary
No
%
100%
100
100
100%
99
99
(2) Counsel individual doctor on admission criteria of alcohol program
100% 100% 100% 100%
63 97
63 97
77
77
(3) Confer with Director of QAP concerning documentation of discharge meds in POMR sys tems 14) Review with individual doctors the need to document the rationale for minor tranquilizers 16 & 7) Inform nursing units of newly established discharge documentation procedure. will re-audit a selected sample in 6 mo
100%
100
100
100% 100% 100% 100% 100% 100%
97 18 87 100 100 81
97 18 87 100 100 81
0
0
Audit Criteria
C
0
Diagnosis 1 (a) (b) lcl Id) (e)
Problems/Actions
Withdrawal signs or Blood alcohol level above 300 mg/100 ml or Memory blanks or Intoxication despite medical contraindications Habitual excessive drinking
I
J 2-
[
Admission 2 la) Desires treatment for permanent abstinence or Ib) Assaultiveness associated with drinking or (c) Outpatient treatment has failed or Id1 Acute exacerbation of alcohol-related medical illness Discharge status 3 Has vitamin supplements to take home 4 All minor tranquilizersdiscontinued 5 All addiclive drugs discontinued 6 After care plan including referral, established and patient advised 7 Family/significant others advised of care plan 8 Mortality
0
? o
Length of stay 9 7 days minimum to 28 days maximum on alcohol unit 10 In-house consult for patients not on alcohol unit 11 T8 skin test 12 EKG 13 Liver function test 14 CBC 15 Chest x-ray
0
-
Complications 16 Oversedationwith or without coma
0%
(12 & 15) Advise the doctor responsible for the medical work-up of alcoholism patients that EKGs and chest x-rays are not being performed on all patients and that these are necessary diagnostic procedures
REFERENCES I . Jacobs CM: PEP for the Uninitiated. QRB, Dec 1975, PP 3-5 2. Essential Characteristics of an Acceptable Patient Care Evaluation Procedure-Audit Action Letter. February 1, 1977
3. Feldman DJ, et al: Outpatient alcohol detoxification: Initial findings on 564 patients. Am J Psychiatry 132:4, 1974 4. West JW: Thegeneral hospital as a primary setting for the treatment of alcoholism. Paper presented before the NCA meeting, Washington DC, 1976
