Feasibility of Implementation of a Phenobarbital Protocol in Management of Alcohol Withdrawal Syndrome at a Safety-Net Hospital

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

Chest

Abstract

PURPOSE: Alcohol withdrawal occurs in more than half of individuals with alcohol-use disorder, and it is associated with high morbidity as well as mortality, resulting in increased healthcare utilization. Our safety-net hospital serving a socioeconomically disadvantaged population in the South Bronx, contends with heightened rates of alcohol/substance use disorders and its associated complication. Given the escalating prevalence, substantial morbidity, and economic impact associated with alcohol-withdrawal syndrome (AWS), phenobarbital emerges as a promising therapeutic option, with evidence of faster symptom resolution, reduced Length of Stay (LOS) and improved healthcare utilization. We explore the feasibility of implementing a phenobarbital driven AWS management, METHODS: Based on a pilot implementation analysis of patients admitted to our hospital for AWS which demonstrated faster symptom resolution, reduced LOS and improved healthcare utilization with phenobarbital, we implemented an evidence-based phenobarbital protocol for treatment of AWS with institutional buy in. Physicians and residents from Internal Medicine and Emergency Medicine were trained in recognizing the severity of AWS and determining the proper dose of phenobarbital through multiple simulated sessions. All involved nursing staff were educated on the protocol over one-month period. With the cooperation from the hospital pharmacy, efforts were made so that phenobarbital was made available in all floors and units. Interviews with physicians, residents, pharmacists and nursing-staff were then used to understand the attitudes, acceptability and barriers with use with respect to implementation of the phenobarbital protocol. A support-group which included residents and fellows was created on the Electronic Medical Record (EMR) where providers could reach out with queries on implementation of the protocol. We present our implementation results from October 2023 through August 2024. RESULTS: Out of 191 patients hospitalized for AWS from October 2023 to August 2024, 111 patients received phenobarbital. Our percentage utilization of phenobarbital increased from 11% in October 2023 to a peak of 95.5% in July 2024. We continued to see improvement in time to symptom resolution from 3.6 days with benzodiazepine use to 1.7 days with phenobarbital use. We also observed improvement in LOS from 6.37 days with benzodiazepine use to 4.7 days with phenobarbital use. CONCLUSIONS: Nursing interviews revealed a positive response in ease of administration of phenobarbital and monitoring of AWS patients after completion of loading dose. The nurses found more time for direct patient care and improved patient responses with treatment because of decreased time required for monitoring when compared to benzodiazepine driven protocol. There was improved satisfaction among physicians as a reduction in direct patient interaction was noted as patient symptoms of AWS resolved faster with decreased LOS and better patient satisfaction. Given the phenobarbital half-life a reduction in medication administration was noted with many patients requiring a single weight-based loading dose which is beneficial for both patients and nursing staff. CLINICAL IMPLICATIONS: The increase utilization for phenobarbital for patients hospitalized with AWS with data supporting safety and efficacy demonstrates that it is feasible and an effective modality in treatment of AWS. Willingness of nurses and physicians with adequate support and education are the drivers for our hospital’s successful implementation of the protocol.

Volume

168

Issue

4S

First Page

4529A

Last Page

4530A

Comments

American College of Chest Physicians CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

DOI

10.1016/j.chest.2025.07.2532

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