Alcohol Withdrawal

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Development of Alcohol Withdrawal Caremap at Houlton Regional Hospital 2009

Alcohol Withdrawal

  1. 1. Alcohol Withdrawal Screening and Treatment
  2. 2. Background <ul><li>We have patients that come to the hospital to have alcohol detoxification and receive help for their disease. </li></ul><ul><li>We also have patients that come to the hospital for another reason such as a fractured hip, but there is also an addiction to alcohol. </li></ul>
  3. 3. <ul><li>Studies on alcohol withdrawal estimate that up to 40% of hospitalized patients have the potential to experience alcohol withdrawal syndrome. </li></ul><ul><li>Our current means of assessing for alcohol consumption and treating alcohol withdrawal is not standardized. </li></ul>
  4. 4. <ul><li>For most people who drink, alcohol is a pleasant addition to eating and to other social activities. </li></ul><ul><li>For most adults drinking a moderate amount of alcohol (up to 2 drinks per day for men, and one drink per day for women and older people) is not harmful. However, some people get into serious trouble because of their drinking. </li></ul>
  5. 5. Evidence Based Practice <ul><li>“ CAGE Tool” </li></ul><ul><li>This assessment tool will determine alcohol use and possible dependency. </li></ul><ul><li>This tool has been used in multiple studies and has documented reliability and validity in clinical settings. The advantage to using CAGE is that it is quick, easy to use, and easy to score. </li></ul><ul><li>Guidelines suggest that patients with a CAGE score greater than 2 should be considered alcohol dependent and at risk for developing alcohol withdrawal syndrome (AWS). </li></ul><ul><li>A score of 1 or greater indicates a possible alcohol dependency. </li></ul>
  6. 6. CAGE Assessment <ul><li>This short assessment will help you determine if your patient might have a problem with alcohol. The name “CAGE” is an acronym formed by taking the first letter of key words from each of the following questions: </li></ul>
  7. 7. CAGE Assessment <ul><li>Have you ever felt you should cut down on your drinking? </li></ul><ul><li>Have people annoyed you by criticizing your drinking? </li></ul><ul><li>Have you ever felt bad or guilty about your drinking? </li></ul><ul><li>Have you ever had a drink first thing in the morning (as an “eye opener”) to steady your nerves or get rid of a hangover? </li></ul>
  8. 8. CAGE Assessment <ul><li>This tool will be used in E.D. triage and ambulatory surgery screenings. </li></ul><ul><li>It will also be part of all admission assessments </li></ul>
  9. 9. E.D. Patients <ul><li>If your patient has a score of 1 or greater: </li></ul><ul><ul><li>During business hours (M-F 7a.m.- 4:00 p.m.): ask the patient if he/she would like to see someone from social services to discuss options for alcohol dependency. You do not need a physician’s order to make a referral to social services. </li></ul></ul><ul><ul><li>After hours: ask the patient if he/she would like some information on services for alcohol dependency and if the answer is yes, provide the patient with pamphlets that will be available in the E.D. </li></ul></ul>
  10. 10. Ambulatory Surgery Patients <ul><li>If your patient has a score of 1 or greater: </li></ul><ul><ul><li>ask the patient if he/she would like to see someone from social services to discuss options for alcohol dependency. You do not need a physician’s order to make a referral to social services. </li></ul></ul>
  11. 11. Acute Care Patients <ul><li>The CAGE assessment will be included in the nursing admission assessment. </li></ul><ul><li>If a patient has a score of 1 or higher: </li></ul><ul><ul><li>Inform the physician that there is potential alcohol dependency with possibility of alcohol withdrawal syndrome (AWS). </li></ul></ul><ul><ul><li>Make a referral to social services (this does not require a physician order). </li></ul></ul>
  12. 12. Signs and Symptoms of Alcohol Withdrawal <ul><li>The mildest form of alcohol withdrawal includes symptoms due to increased CNS and sympathetic activity. These usually consist of </li></ul><ul><ul><li>Agitation </li></ul></ul><ul><ul><li>Increased sweating </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Increased hand tremor </li></ul></ul><ul><ul><li>GI upset </li></ul></ul><ul><ul><li>Insomnia </li></ul></ul><ul><ul><li>Palpitations </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul>
  13. 13. <ul><li>Alcoholic hallucinosis may also be present in the form of transient tactile, visual or auditory hallucinations, with visual being the most common. </li></ul><ul><li>Seizures may also occur and are usually generalized tonic-clonic convulsions occurring within the first 48 hours after the last drink. </li></ul>
  14. 14. <ul><li>The most severe form of alcohol withdrawal is delirium tremens (DT’s), which carries a mortality risk of 1-5% </li></ul><ul><li>In-patients experiencing alcohol withdrawal have approximately a 5% chance of developing DT’s. </li></ul><ul><li>Death, when it occurs in DT’s, is usually due to arrhythmias or complications from the DT’s, such as pneumonia. </li></ul>
  15. 15. Risk Factors for Developing DT’s <ul><li>History of sustained drinking </li></ul><ul><li>Age greater than 30 </li></ul><ul><li>History of previous DT’s </li></ul><ul><li>Presence of concurrent illness </li></ul><ul><li>Greater number of days since last drink </li></ul>
  16. 16. Characteristic Features of DT’s <ul><li>Hallucinations </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Agitation </li></ul><ul><li>Low grade fever </li></ul><ul><li>Tachycardia </li></ul><ul><li>Hypertension </li></ul><ul><li>Disorientation </li></ul>
  17. 17. CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Withdrawal – revised) <ul><li>This is a scale to assess the physical and psychological symptoms according to severity (“not present” to “extremely severe”) and medicate based on the objective data including: </li></ul><ul><ul><li>Agitation </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Auditory disturbances </li></ul></ul><ul><ul><li>Clouding of the senses </li></ul></ul><ul><ul><li>Headaches </li></ul></ul><ul><ul><li>Nausea and vomiting </li></ul></ul><ul><ul><li>Paroxysmal sweats </li></ul></ul><ul><ul><li>Tactile disturbances </li></ul></ul><ul><ul><li>Tremors </li></ul></ul><ul><ul><li>Visual disturbances </li></ul></ul>
  18. 18. <ul><li>Once the data are collected, a total score is obtained; the maximum score is 67 </li></ul><ul><li>The patient is medicated for alcohol withdrawal based on the score received. </li></ul>
  19. 19. <ul><li>Studies on use of the CIWA-Ar have concluded: </li></ul><ul><ul><li>The CIWA-Ar is an effective guide in directing medication administration. </li></ul></ul><ul><ul><li>Using the CIWA-Ar leads to an improvement in the appropriateness of pharmacotherapy without a difference in morbidity. </li></ul></ul><ul><ul><li>When the scale is used, patients with a greater dependence, and hence worse withdrawal receive greater amounts of medicine and vice versa. Thus, there is a titration of drug administration to therapeutic requirement in a more appropriate manner. </li></ul></ul>
  20. 20. <ul><li>Studies on use of the CIWA-Ar have concluded: </li></ul><ul><ul><li>A lower average of medication used in the CIWA-Ar leads to financial savings without increasing the rate of complications. </li></ul></ul><ul><ul><li>The use of the CIWA-Ar scale can also help in writing the appropriate amount of prn medication. </li></ul></ul>
  21. 21. CIWA-Ar <ul><li>NAUSEA AND VOMITING </li></ul><ul><li>-- Ask &quot;Do you feel sick to your </li></ul><ul><li>stomach? Have you vomited?&quot; </li></ul><ul><li>Observation. </li></ul><ul><li>0 no nausea and no vomiting 1 mild nausea with no vomiting 2 3 4 intermittent nausea with dry heaves 5 6 7 constant nausea, frequent dry heaves and vomiting </li></ul>
  22. 22. CIWA-Ar <ul><li>TACTILE DISTURBANCES </li></ul><ul><li>-- Ask &quot;Have you any itching, pins and </li></ul><ul><li>needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?” </li></ul><ul><li>Observation. </li></ul><ul><li>0 none 1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations </li></ul>
  23. 23. CIWA-Ar <ul><li>TREMOR </li></ul><ul><li>-- Arms extended and fingers spread apart. </li></ul><ul><li>Observation. </li></ul><ul><li>0 no tremor 1 not visible, but can be felt fingertip to fingertip 2 3 4 moderate, with patient's arms extended 5 6 7 severe, even with arms not extended </li></ul>
  24. 24. CIWA-Ar <ul><li>AUDITORY DISTURBANCES </li></ul><ul><li>-- Ask &quot;Are you more aware of </li></ul><ul><li>sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?&quot; </li></ul><ul><li>Observation. </li></ul><ul><li>0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations </li></ul>
  25. 25. CIWA-Ar <ul><li>PAROXYSMAL SWEATS </li></ul><ul><li>-- Observation. </li></ul><ul><li>0 no sweat visible 1 barely perceptible sweating, palms moist 2 3 4 beads of sweat obvious on forehead 5 6 7 drenching sweats </li></ul>
  26. 26. CIWA-Ar <ul><li>VISUAL DISTURBANCES </li></ul><ul><li>-- Ask &quot;Does the light appear to be too </li></ul><ul><li>bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?” </li></ul><ul><li>Observation. </li></ul><ul><li>0 not present 1 very mild sensitivity 2 mild sensitivity 3 moderate sensitivity 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations </li></ul>
  27. 27. CIWA-Ar <ul><li>ANXIETY </li></ul><ul><li>-- Ask &quot;Do you feel nervous?&quot; Observation. </li></ul><ul><li>0 no anxiety, at ease 1 mild anxious 2 3 4 moderately anxious, or guarded, so anxiety is inferred 5 6 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions </li></ul>
  28. 28. CIWA-Ar <ul><li>HEADACHE, FULLNESS IN HEAD </li></ul><ul><li>-- Ask &quot;Does your head feel </li></ul><ul><li>different? Does it feel like there is a band around your head?&quot; Do not rate for dizziness or lightheadedness. Otherwise, rate severity. </li></ul><ul><li>0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe </li></ul>
  29. 29. CIWA-Ar <ul><li>AGITATION </li></ul><ul><li>-- Observation. </li></ul><ul><li>0 normal activity 1 somewhat more than normal activity 2 3 4 moderately fidgety and restless 5 6 7 paces back and forth during most of the interview, or constantly thrashes about </li></ul>
  30. 30. CIWA-Ar <ul><li>ORIENTATION AND CLOUDING OF SENSORIUM </li></ul><ul><li>-- Ask </li></ul><ul><li>&quot;What day is this? Where are you? Who am I?&quot; </li></ul><ul><li>0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about date 2 disoriented for date by no more than 2 calendar days 3 disoriented for date by more than 2 calendar days 4 disoriented for place/or person </li></ul>
  31. 31. CIWA-Ar <ul><li>Total CIWA-Ar Score ______ </li></ul><ul><li>Maximum Possible Score 67 </li></ul><ul><li>The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 9 do not usually need additional medication for withdrawal. </li></ul>
  32. 32. Management of Patients with Alcohol Withdrawal Syndrome <ul><li>Most signs and symptoms of alcohol withdrawal are caused by the rapid removal of the depressant effects of alcohol in the central nervous system. </li></ul><ul><li>The cornerstone of pharmacological management for AWS patients is benzodiazepines. They reduce the severity if the effects of alcohol withdrawal and prevent progression to the serious complications of AWS. </li></ul>
  33. 33. HRH Alcohol Withdrawal Protocol <ul><li>The protocol has a stop date of 72 hours. The provider must assess need and reorder if necessary. </li></ul><ul><li>The following interventions are based upon the results of the CIWA-Ar assessment scale. </li></ul><ul><li>Verify date (_______) and time (_______) of patient’s last alcohol consumption. </li></ul><ul><li>Do not initiate protocol if respiratory rate is less than 10 breaths/min. </li></ul><ul><li>Vital signs every 4 hours. </li></ul><ul><li>Labs (if not drawn in ED): CBC, BMP, Protime/PTT, Mg, Phosphorus, LFT’s,U/A, Urine drug screen, Urine HCG for women of childbearing age. </li></ul><ul><li>If patient is receiving benzodiazepines more often than every 2 hours –continuous O2 sat monitor and telemetry. </li></ul><ul><li>Physician will order one of the following protocols: </li></ul><ul><li>Lorazepam (Ativan) Protocol:CIWA-Ar Score </li></ul><ul><li>Less than 9 points None </li></ul><ul><li>9-10 points 1 mg IV, IM or PO (indicate route) every 60 min prn 11-13 points 2 mg IV, IM or PO (indicate route) every 60 min prn </li></ul><ul><li>14-16 points 4 mg IV, IM or PO (indicate route) every 60 min prn Greater than 16 points 5 mg IV, IM or PO (indicate route) every 60 min prn </li></ul>
  34. 34. HRH Alcohol Withdrawal Protocol cont’d <ul><li>Chlorodiazepoxide (Librium) Protocol:CIWA-Ar Score: </li></ul><ul><li>Less than 9 points None </li></ul><ul><li>9-10 points 25 mg PO every 60 min prn </li></ul><ul><li>11-13 points 50 mg PO every 60 min prn </li></ul><ul><li>14-16 points 75 mg PO every 60 min prn </li></ul><ul><li>Greater than 16 points 100 mg PO every 30 min prn </li></ul><ul><li>And notify provider </li></ul><ul><li>Following initial CIWA-Ar scoring, repeat scoring: </li></ul><ul><ul><li>every 4 hours if score is less than 9. </li></ul></ul><ul><ul><li>if score is 9 or greater, medicate per protocol and recheck score and reassess patient in 1 hour. </li></ul></ul>
  35. 35. HRH Alcohol Withdrawal Protocol cont’d <ul><li>Notify provider if: </li></ul><ul><li>Any CIWA-Ar score greater than 16 (also notify rapid response team for score greater than16). </li></ul><ul><li>There is no improvement after four consecutive assessments (including the baseline). </li></ul><ul><li>The patient has received more than 6 mg of Lorazepam OR 300 mg of Librium in a 3 hour period. </li></ul><ul><li>Respiratory Rate is less than 10 breaths/min. </li></ul><ul><li>Code green should be instituted for potentially violent behavior. </li></ul><ul><li>May discontinue protocol if the CIWA-Ar score is less than 8 for a 24 hour period in which no benzodiazepines were administered. </li></ul><ul><li>Nurse Signature ___________________________ Date/Time: ________________ </li></ul>
  36. 36. <ul><li>The alcohol withdrawal protocol may be utilized on any patient admitted (over the age of 18) that is experiencing alcohol withdrawal, regardless if alcohol withdrawal is the primary diagnosis. </li></ul>
  37. 37. Alcohol Withdrawal Caremap <ul><li>Patients who are admitted with a primary diagnosis of alcohol withdrawal will be placed on the alcohol withdrawal Caremap. </li></ul><ul><li>Patients who are admitted with a primary diagnosis other than alcohol withdrawal (e.g. fractured hip) but are experiencing withdrawal, will have alcohol withdrawal added as a secondary diagnosis. </li></ul>
  38. 38. Summary <ul><li>HRH does not currently have a standardized method of assessing for alcohol dependence and treating alcohol withdrawal. </li></ul><ul><li>CAGE assessments will be implemented on all acute care admissions, in the ED and on ASU units. </li></ul><ul><li>The Alcohol Withdrawal Protocol will be ordered by the physician if indicated. He will choose either a lorazepam or librium protocol. </li></ul>
  39. 39. Summary cont’d <ul><li>An alchol withdrawal Caremap will be implemented on all patients with a primary diagnosis of alcohol withdrawal. </li></ul><ul><li>Nurses will be trained on how to administer CIWA-Ar scoring. </li></ul>

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