Care Failures for a Patient with Alcohol Withdrawal at the Hampton VA Medical Center in Virginia

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a congressional referral regarding the care of a patient who was admitted for alcohol withdrawal and later died at the Hampton VA Medical Center (facility) in Virginia.

The OIG identified failures in the management of alcohol withdrawal symptoms of this complex patient by nursing staff and providers. Nursing staff failed to accurately and timely assess the patient’s alcohol withdrawal symptoms and consistently administer medications in adherence with the facility’s Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) protocol used to determine the severity of the symptoms and clinical response. Additionally, the OIG found concerns with the timeliness of nursing staff’s electronic health records (EHR) documentation of CIWA-AR assessment scores. Delayed entries of assessment scores may affect providers’ clinical decisions. These failures may have affected the overall management of the patient’s alcohol withdrawal symptoms.

The OIG determined that facility providers failed to recognize the severity of the patient’s alcohol withdrawal. Based on past medical history and admissions, the patient was considered high risk for developing delirium, a severe form of alcohol withdrawal. According to clinical guidelines, delirium can be effectively treated with a benzodiazepine medication such as lorazepam. The OIG found one provider did not confirm the availability of lorazepam before making a clinical decision to use another medication that was not a benzodiazepine. Another provider documented symptoms suggestive of severe alcohol withdrawal but failed to identify several risk factors of severe withdrawal and treat the symptoms. These failures likely contributed to the patient not being afforded evidence-based care for prevention of delirium and severe alcohol withdrawal.

The OIG made seven recommendations to the Facility Director related to compliance with facility CIWA-AR protocol, CIWA assessment, and the management of severe alcohol withdrawal.