Unintended consequences of a quality improvement program designed to improve treatment of alcohol withdrawal in hospitalized patients.

Background: New guidelines, accompanied by an educational campaign, introduced standardized monitoring of withdrawal severity while emphasizing prophylactic fixed-schedule benzodiazepine (BDZ) treatment of at-risk patients.

Evaluation: Preliminary analysis showed more deaths during the year after introduction of the guidelines. Investigation revealed some evidence of guideline adherence and a decrease in the number of patients requiring transfer to a higher level of care. However, an 18% increase in the median length of stay was also found, as was an increase in the total dose of benzodiazepines administered to patients with cirrhosis and severe concurrent illness, and the risk of in-hospital death persisted even after adjustment for patient mix.

Response: This feedback led to guideline revision and redoubled educational efforts focused on safe benzodiazepine prescribing. Ongoing monitoring of patient outcomes showed no further deterioration and some evidence of improved quality of care.

Conclusion: Evaluation of such quality improvement efforts should include measurement of both treatment patterns and patient outcomes.