Implementation of a Phenobarbital-based Pathway for Severe Alcohol Withdrawal: A Mixed-Method Study

Area of Science:

• Critical Care Medicine
• Pharmacology
• Quality Improvement Initiatives

Background:

• Alcohol withdrawal syndrome (AWS) management in intensive care units (ICUs) often relies on benzodiazepines.
• Phenobarbital-based pathways are increasingly adopted, but their ICU-specific process, effectiveness, and safety remain underexplored.
• Severe AWS in the ICU necessitates rigorous evaluation of novel treatment protocols.

Purpose of the Study:

• To assess clinician acceptability and feasibility of a phenobarbital-based pathway for severe AWS in a medical ICU (MICU).
• To evaluate patient outcomes, including mechanical ventilation rates, physical restraint use, and hospital length of stay, following the implementation of the phenobarbital pathway.
• To compare the phenobarbital pathway against a previous benzodiazepine-based pathway for severe AWS treatment.

Main Methods:

• A mixed-method study incorporating qualitative interviews and surveys for clinician feedback on pathway acceptability and feasibility.
• A noninferiority interrupted-time-series analysis comparing mechanical ventilation rates before and after phenobarbital pathway implementation.
• Exploration of secondary outcomes such as physical restraint use and hospital length of stay in a safety-net hospital setting.

Main Results:

• Clinician feedback highlighted pathway design balancing standardization with judgment, simplicity, streamlined workflow, and effective implementation strategies as key to acceptability and feasibility.
• Mechanical ventilation rates decreased from 17.1% to 12.9% post-implementation, demonstrating noninferiority compared to the benzodiazepine pathway (adjusted mean difference -4.9%, 95% upper CI: 0.7%).
• Significant reductions were observed in physical restraint use (51.6% to 32.4%) and hospital length of stay (8.6 to 6.8 days).

Conclusions:

• Clinicians perceived the phenobarbital pathway as more efficient and simpler to manage for severe alcohol withdrawal syndrome.
• The phenobarbital pathway achieved noninferiority in mechanical ventilation rates compared to the benzodiazepine pathway.
• Implementation of the phenobarbital pathway led to improved patient outcomes, including decreased need for physical restraints and shorter hospital stays.