Veterans Health Administration Needs More Written Guidance to Better Manage Inpatient Management of Alcohol Withdrawal

The OIG reviewed the Veterans Health Administration’s (VHA’s) assessment and management of inpatient alcohol withdrawal following several OIG inspections where adverse clinical outcomes associated with alcohol withdrawal, likely contributing to patient deaths, were identified. Determining the severity of alcohol withdrawal is critical in facilitating treatment decisions that may prevent the progression of symptoms which could be fatal. Inpatient management of alcohol withdrawal is not specifically addressed in current VHA clinical guidance, and it does not fall under one VHA national program office. The OIG evaluated national and system-level written guidance for specificity to inpatient management of alcohol withdrawal in four key areas: determination of alcohol withdrawal severity, inpatient treatment of alcohol withdrawal, inpatient staff training for assessing alcohol withdrawal severity, and oversight for inpatient management of alcohol withdrawal (guidance and monitoring). The OIG found healthcare systems lacked written guidance related to assessing and reassessing alcohol withdrawal severity; determining the appropriate inpatient level of care; evaluating co-occurring conditions; consulting with substance use disorder experts; and pharmacotherapy. Written guidance was also lacking for when nurses should consult prescribers based on patients' alcohol withdrawal severity, when prescribers should evaluate patients face-to-face based on nursing assessment findings, and when to transfer care. Written guidance for inpatient management of alcohol withdrawal could decrease the risk of adverse patient safety outcomes and, along with training, facilitate knowledge of proper administration and consistency of assessments. Detailed expectations for oversight and monitoring would allow for quality of care to be evaluated and assessed for compliance with available substance use disorder guidance. The OIG made three recommendations to the Under Secretary for Health related to consideration of identifying a national office responsible for oversight, implementing written guidance for the management of alcohol withdrawal across inpatient settings, and implementing inpatient staff training on standardized alcohol withdrawal severity scales.