Fixed-Dose Phenobarbital Versus As-Needed Benzodiazepines for the Management of Alcohol Withdrawal in Acute Care General Internal Medicine.

OBJECTIVES: The management of patients at risk of severe alcohol withdrawal is challenging because conventional treatment with as-needed benzodiazepines may be ineffective. We created a fixed-dose phenobarbital protocol and compared patient outcomes using this protocol with an as-needed benzodiazepine protocol. METHODS: Patients admitted from the emergency department (ED) to General Medicine from January 1 to June 30, 2022 and treated for alcohol withdrawal with a novel phenobarbital protocol were compared with all of the patients admitted from the ED to General Medicine from January 1 to June 30, 2018, and treated with as-needed benzodiazepines. The primary outcome was a composite of intensive care unit (ICU) transfer or mortality. Secondary outcomes included mortality, ICU transfer, seizure, length of stay, excess sedation, delirium, against medical advice discharge, 30-day re-admission, 30-day ED reevaluation, and antipsychotic use. RESULTS: There were 54 patients in the phenobarbital group and 197 in the benzodiazepine group. The phenobarbital group was less medically complex but had more risk factors for severe withdrawal. There was no difference in the primary outcome, although there was a trend toward benefit in the phenobarbital group (3.7 vs 8.1%, P = 0.26), and there was a lower incidence of delirium in the phenobarbital cohort (0 vs 8.6%, P = 0.03). Secondary outcome trends favored phenobarbital, with lower mortality, ICU transfer, seizure, oversedation, against medical advice discharge, and 30-day re-admissions. A subgroup analysis accounting for differences in patient populations in the primary analysis found similar results. CONCLUSIONS: Phenobarbital is as safe and effective as benzodiazepine-based protocols for the treatment of high-risk alcohol withdrawal, with lower rates of delirium.

Number of General Medicine Hospital Admissions Performed by Internal Medicine Residents Before and After the 2011 Duty-Hour Regulations.

OBJECTIVES: In July 2011 the Accreditation Council for Graduate Medical Education implemented new resident duty-hour regulations in an effort to improve resident well-being, clinical performance, and patient care. These regulations have the potential, however, to reduce the number of new patient encounters handled by trainees and thereby could be detrimental to resident education. Our objective was to describe how the 2011 duty-hour regulations affected the volume of new inpatient general medicine encounters at two large academic medical centers. We looked specifically at new patient encounters because we assumed they provided the richest learning opportunities. We hypothesized that the implementation of the Accreditation Council for Graduate Medical Education regulations would be associated with a reduction in the number of new admissions per day and result in a decrease in the number of annual admissions performed by first-year medical residents. METHODS: We conducted a retrospective ecological study. We reviewed general medicine admissions data from two large academic hospitals affiliated with the University of Washington: Harborview Medical Center and the University of Washington Medical Center. We abstracted the number of admissions, source of admission, and average intern census on 56 randomly selected days before and after the regulations were implemented (academic years 2010-2011 [AY11] and 2011-2012 [AY12]). We generated descriptive statistics (means, proportions, and 95% confidence intervals) and then used a two-sample t test to compare the number of admissions per day, admission source, and average daily intern census between AY11 and AY12. RESULTS: At the University of Washington Medical Center, single-intern teams admitted 4.5 patients per day in AY11 compared with 3.1 in AY12 (P < 0.001). At Harborview Medical Center, two-intern teams admitted 11.1 patients per day in AY11 versus 7.9 in AY12 (P < 0.001). Night interns admitted 0.9 patients per shift in AY11 versus 2.4 in AY12 (P < 0.001). After implementing the new duty hours, daytime admissions from the emergency department decreased and admissions as transfers from the intensive care unit increased. The average intern census was not affected by the duty-hour regulations. CONCLUSIONS: Medicine residents admit fewer patients on daytime inpatient general medicine services under the new duty-hour regulations; however, this is completely offset by an increase in the number of admissions performed on the night rotation, resulting in no net change in the total number of new inpatient encounters handled by first-year medical residents during the course of the academic year. Although this is reassuring, changes that were made in response to the work-hour rules have altered how new admissions are distributed to teams, which has important implications for curricular design and supervision.