Annotated Bibliography

Alcoholism is the most common form of substance abuse disorder worldwide in which an individual engages in unhealthy consumption of alcohol and the common symptoms include craving for alcohol, spending lot of resource on alcohol consumption and experiencing temporary blackouts (Mendoza, 2018). Another issue is that people who try to abstain from alcohol starts developing alcohol withdrawal syndrome resulting in added complications for affected individuals (Shu,  Lin & Chang, 2015).Hence, this topic interests me because clinical problem of alcohol withdrawal creates additional risk and uncertainty in addiction cessation treatment. As a registered nurse, I am also interested in identifying the best way to address the problem so that I am able to manage complexities and morbidities in patients with alcohol withdrawal (Berl et al., 2015). Hence, using the principles of evidence based practice, I aim to critically evaluate three best practice evidences that can give idea regarding the suitable interventions to treat patients with alcohol withdrawal syndrome and find it relevance with clinical expertise and patients values.

Gashlin, L. Z., Groth, C. M., Wiegand, T. J., & Ashley, E. D. (2015). Comparison of alcohol withdrawal outcomes in patients treated with benzodiazepines alone versus adjunctive phenobarbital: a retrospective cohort study. Asia Pacific Journal of Medical Toxicology, 4(1), 31-36. Retrieved from: https://eprints.mums.ac.ir/7875/1/APJMT_Volume%204_Issue%201_Pages%2031-36.pdf

Level 4 (Retrospective cohort study)

Gashlin et al. (2015) revealed that the problem associated with high dose benzodiazepines (BZDs) because of over-sedation effect on patient. In response to this problem, the author suggested Phenobarbital (PBT) as an alternative option for the management of alcohol withdrawal. The main purpose of research was to evaluate the effectiveness of PBT as an adjunctive therapy for alcohol withdrawal treatment. The retrospective cohort study included those patients who were treated either with BZD alone or BZDs with adjunctive PBT. In the two groups, the CIWA score (Tool for alcohol withdrawal) was recorded 24 hours after first dose and safety end points such as need for intubation, seizures, hemodynamic stability and mortality was recorded in both groups of patients. The statistical analysis of research data gave the indication that median duration of withdrawal symptoms of only 44 hours in the PBT-adjunct group compared to 53 hours only in the BZD group. The conclusion from the results was that PBT can be a safe alternative to BZDs for treatment of alcohol withdrawal patients.

Barrett, J., Jansen, M., Cooper, A., Felbinger, M., & Waters, F. (2016). Embracing a nurse-driven alcohol withdrawal protocol through quality improvement. Journal of addictions nursing, 27(4), 234-240. DOI: 10.1097/JAN.0000000000000142

Justifying the Evidence

Level 4(Retrospective cohort study)

The study by Barrett et al. (2016) gave an insight the importance of symptom triggered protocols in decreasing alcohol withdrawal rate and problem of nurse’s non-compliance to such protocols. The main aim of the study was to evaluate whether implementing educational program can improve nursing compliance with alcohol withdrawal protocol or not. The retrospective study was done in two stages. The first stage comprised conducting initial needs assessment followed by nursing education and the second stage involved retrospective review after education. Visual algorithm was used to simplify the alcohol withdrawal protocol and guide nurses regarding the alcohol withdrawal pathway. The primary outcome of interest was nurse’s compliance rate and secondary outcome included hospital stay and CIWA score for assessment of alcohol withdrawal. The statistical analysis of research data revealed increase in compliance of 1-hour assessment after the educational intervention. However, major difference was not found for 6-hour assessment. The author concluded that nursing education has the potential to improve compliance with alcohol withdrawal protocol, but future study must evaluate the impact of assessment frequency intervals on patient outcomes.

Frazee, E. N., Personett, H. A., Leung, J. G., Nelson, S., Dierkhising, R. A., & Bauer, P. R. (2014). Influence of dexmedetomidine therapy on the management of severe alcohol withdrawal syndrome in critically ill patients. Journal of critical care, 29(2), 298-302. Doi https://dx.doi.org/10.1016/j.jcrc.2013.11.016

Level 4 evidence (cross sectional cohort study)

Frazee et al. (2014) is a well-published research paper that introduced the problem associated with the use of BZDs as a first line drug for alcohol withdrawal. The main concern was that increasing the dose may lead to extra complications and little clinical benefits. The author aimed to evaluate the efficacy of dexmedetomidine (a rapid onset and short duration of action highly selective α2-adrenergic agonist) on affecting the hemodynamics of patients with alcohol withdrawal. The retrospective analysis was done with critically ill patients with primary ICU admission for alcohol withdrawal and treatment with dexmedetomidine. Incremental titration was used to increase the desired depth of sedation. The clinical outcomes were assessed based on CIWA-Ar score within 24 hours of admission. The study findings reveal that dexmedetomidine decreased the need for BZDs in patient and enhances hemodynamic stability in patients with alcohol withdrawal. The author concluded that use of dexmedetomidine along with BZDs is effective treatment option for reducing adverse outcome and achieving symptom control in patient.

Out of the three best practice evidence selected, the retrospective cohort study by Barrett et al. (2016) was conducted in a 369 bed community hospital in the United States. The strength of this research paper is that instead of just implementing the education intervention, the author added a needs assessment element in the retrospective review. This step helped to identify the level of training and knowledge gap of nurses as well as understand the type of training or education needed by health care staffs. This type of methodology increases the practical relevance of data as it considers daily challenges experienced by clinical staffs while addressing any research topic. Gaspard and Yang (2016) recommends needs assessment before implementing any educational program in order to guide the policy making process related to training needs and the development of training programs for different level of health care professionals. This is good strategy to address resource limitation and skills gaps of health care staffs. By the use of needs assessment, several areas of improvement in the treatment of alcohol withdrawal could be identified (Barrett et al., 2016). Based on needs assessment process, important strategies like improving screening process, duration of CIWA assessment and complying with treatment protocol was identified. Hence, this research is found very relevant to be used in clinical setting as it examined barriers faced in practical setting while implementing treatment. The methodology used for needs assessment is credible and reliable in terms of evidence based practice too as clinical expertise is considered before designing an intervention (Greenhalgh, Howick & Maskrey, 2014).

The main rational behind identifying the study by Gashlin et al. (2015) as one of the best practice evidence is that it used  analysis of long duration data within the year 2006 to June 2012. Furthermore, the quality of the work is understood from the fact that it took additional consideration to improve the reliability of the intervention. For example, standardized protocol for alcohol withdrawal treatment was available for all staffs thus reducing chances of bias in research outcome because of structural or practical barriers in care. Pannucci and Wilkins (2010) explains that bias can occur in the planning, data collection and analysis phase of research and thorough understand and consideration of bias can promote evidence based practice. Hence, the study finding is reliable.

In contrast to Barrett et al. (2016) which used educational intervention to improve overall treatment pathway related to alcohol withdrawal, the two paper by Frazee et al. (2014) and Gashlin et al. (2015) focused on addressing challenges in the use of BZDs for patients with alcohol withdrawal. Frazee et al. (2014) the use of adjunctive PBT for treatment of alcohol withdrawal. In case of retrospective research design, the researchers looks back at cohort based data and examines exposure to risk in relation to particular outcome (Zeng et al., 2015). In accordance with the research design, Frazee et al. (2014) examined cohort group who received either BZD or BZD with PBT treatment. Furthermore, it used validated tool called CIWA for assessment of improvement in symptoms of patient. Walton et al. (2015) justifies that patient assessment is an end point for representation of health status of patients after an intervention.  Hence, use of validated tool and comparison of treatment and control group helped to examine the true effect of the intervention. This process increased transparency in research work and increased the reliability of research outcome. Hence,

However, certain limitations have been found for the three studies too. For example, Barrett et al. (2016) conducted the retrospective analysis in a single setting with a small sample size. This affected the transferability of the findings because the findings cannot be generalized for other setting.  Hence, estimation of appropriate sample size was important. Faber and Fonseca,(2014) explains that too small sample size can affect identifying clinically relevant difference in outcome in different setting thus preventing the findings from being extrapolated. In addition, too large sample size amplifies the detection of differences resulting in clinically irrelevant data. Furthermore, as all the research papers had retrospective cohort study design, estimation of appropriate sample size was necessary to interpret risk of exposure (Charan & Biswas, 2013). However, small sample size and single hospital or single clinic evaluation of data was a major limitation for all the three papers.  This limitation needs to be addressed in future research.

To apply the evidence in nursing practice, it is necessary to critically evaluate the application of research papers in terms of the principles of evidence based practice. According to evidence based practice, it is necessary to critically evaluate the research evidence and its application in clinical practice by consideration of patients value, clinical expertise and clinical context (DiCenso, Guyatt & Ciliska, 2014).In this context, the research paper by Barret et al. (2016) is considered the best evidence to be applied in nursing practice. This can be said because it considered the clinical expertise of nurses before implementing the educational intervention. It also took steps to simplify the protocol so that maximum adherence to protocol could be achieved. By the inclusion of needs assessment step in the research methodology, the research showed that practical concerns faced by nurses during alcohol withdrawal treatment was addressed. For example, by the use of needs assessment, the researcher was able to identify delays in CIWA assessment for patient and presence of variety of treatment plans for patient. This finding gave the guidance to identify areas of improvement and find out the common reason behind non-compliance with alcohol withdrawal treatment protocol among nurses. Feeney et al. (2015) also gives the justification that certain restraining forces exist in health care setting which restricts nurses from following the alcohol withdrawal protocol. Hence, as Barrett et al. (2016) has considered clinical expertise before implementing the intervention, the evidence can be applied in nursing practice. Nursing administrators can take similar steps to embrace the intervention in real setting.

The study by Barrett et al. (2016) can also be applied in nursing practice because it has no risk of challenging patient values. Instead, it encouraged regular monitoring and assessment of patient from the time of admission. Hence, this would increase patient satisfaction with care and increase patient-nurse engagement too.

References

Barrett, J., Jansen, M., Cooper, A., Felbinger, M., & Waters, F. (2016). Embracing a nurse-driven alcohol withdrawal protocol through quality improvement. Journal of addictions nursing, 27(4), 234-240. DOI: 10.1097/JAN.0000000000000142

Berl, K., Collins, M. L., Melson, J., Mooney, R., Muffley, C., & Wright-Glover, A. (2015). Improving Nursing Knowledge of Alcohol Withdrawal: Second Generation Education Strategies. Journal for Nurses in Professional Development, 31(6), 328–332. https://doi.org/10.1097/NND.0000000000000176

Charan, J., & Biswas, T. (2013). How to Calculate Sample Size for Different Study Designs in Medical Research? Indian Journal of Psychological Medicine, 35(2), 121–126. https://doi.org/10.4103/0253-7176.116232

DiCenso, A., Guyatt, G., & Ciliska, D. (2014). Evidence-Based Nursing-E-Book: A Guide to Clinical Practice. Elsevier Health Sciences. Retrieved from: https://www.feliceapicella.it/nurs.pdf

Faber, J., & Fonseca, L. M. (2014). How sample size influences research outcomes. Dental Press Journal of Orthodontics, 19(4), 27–29. https://doi.org/10.1590/2176-9451.19.4.027-029.ebo

Feeney, C., Alter, H. J., Jacobsen, E., Rehrer, M., Shao, S., Subramanian, I., & Clements, R. C. (2015). A simplified protocol for the treatment of alcohol withdrawal. Journal of addiction medicine, 9(6), 485-490. doi: 10.1097/ADM.0000000000000167

Frazee, E. N., Personett, H. A., Leung, J. G., Nelson, S., Dierkhising, R. A., & Bauer, P. R. (2014). Influence of dexmedetomidine therapy on the management of severe alcohol withdrawal syndrome in critically ill patients. Journal of critical care, 29(2), 298-302. Doi https://dx.doi.org/10.1016/j.jcrc.2013.11.016

Gashlin, L. Z., Groth, C. M., Wiegand, T. J., & Ashley, E. D. (2015). Comparison of alcohol withdrawal outcomes in patients treated with benzodiazepines alone versus adjunctive phenobarbital: a retrospective cohort study. Asia Pacific Journal of Medical Toxicology, 4(1), 31-36. Retrieved from: https://eprints.mums.ac.ir/7875/1/APJMT_Volume%204_Issue%201_Pages%2031-36.pdf

Gaspard, J., & Yang, C.-M. (2016). Training needs assessment of health care professionals in a developing country: the example of Saint Lucia. BMC Medical Education, 16, 112. https://doi.org/10.1186/s12909-016-0638-9

Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: a movement in crisis?. Bmj, 348, g3725.

Mendoza, R. L. (2018). Is medical treatment of Alcohol Withdrawal Syndrome a Stag Hunt? Challenges and opportunities in managing risk and uncertainty in addiction cessation. Risk Management and Healthcare Policy, 11, 1–14. https://doi.org/10.2147/RMHP.S144831

Pannucci, C. J., & Wilkins, E. G. (2010). Identifying and Avoiding Bias in Research. Plastic and Reconstructive Surgery, 126(2), 619–625. https://doi.org/10.1097/PRS.0b013e3181de24bc

Shu, J. E., Lin, A., & Chang, G. (2015). Alcohol withdrawal treatment in the medically hospitalized patient: a pilot study assessing predictors for medical or psychiatric complications. Psychosomatics, 56(5), 547-555. https://doi.org/10.1016/j.psym.2014.12.002

Walton, M. K., Powers, J. H., Hobart, J., Patrick, D. L., Marquis, P., Vamvakas, S., … Burke, L. (2015). Clinical Outcome Assessments: Conceptual Foundation–Report of the ISPOR Clinical Outcomes Assessment – Emerging Good Practices for Outcomes Research Task Force DOES THIS HAVE TO BE LABLED AS PART 1. Value in Health?: The Journal of the International Society for Pharmacoeconomics and Outcomes Research, 18(6), 741–752. https://doi.org/10.1016/j.jval.2015.08.006

Zeng, X., Zhang, Y., Kwong, J. S., Zhang, C., Li, S., Sun, F., … & Du, L. (2015). The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta?analysis, and clinical practice guideline: a systematic review. Journal of evidence-based medicine, 8(1), 2-