SummaryAn algorithm-driven program at Christiana Care Health System combines hospital-wide inpatient screening for alcohol withdrawal risk, further assessment of those screening positive, and ongoing treatment and monitoring as necessary. Nurses screen all admitted patients using a validated risk assessment tool; if a patient screens positive, the nurse administers a second questionnaire that evaluates severity of withdrawal symptoms. As necessary, physicians initiate algorithm-based treatment using an established order set that specifies the dosage and timing of medication based on the patient's symptom severity. The algorithm also guides ongoing symptom reassessment, vital sign monitoring, and medication dose adjustment. The program helped to identify more patients with alcohol withdrawal and to prevent development of delirium tremens (a dangerous, acute episode of delirium caused by alcohol withdrawal). It also improved care for patients with delirium tremens, as evidenced by shorter average length of stay, less use of restraints, and fewer transfers to the intensive care unit.Moderate: The evidence consists of pre- and post-implementation comparisons of key outcome measures, including the percentage of patients diagnosed with alcohol withdrawal, the percentage of patients with alcohol withdrawal developing delirium tremens, length of stay, restraint use, and intensive care unit transfers of patients with delirium tremens.
Developing OrganizationsChristiana Care Health System
Date First Implemented2009
Vulnerable Populations > Substance abusers
Problem AddressedPatients with alcohol dependency frequently experience withdrawal symptoms while hospitalized, with some developing delirium tremens (DTs), a dangerous form of withdrawal that can be fatal. Although hospitals can proactively provide patients with treatment to avoid or ameliorate alcohol withdrawal symptoms, most do not identify patients in withdrawal until severe symptoms arise.
- A common problem: According to the American Medical Association, approximately 20 percent of hospitalized adults have alcohol problems; in Delaware, an estimated 7 percent of adults are heavy drinkers.1
- Leading to withdrawal symptoms during hospitalization: Alcohol withdrawal symptoms occur when a person dependent on alcohol suddenly stops drinking.2 These symptoms may be mild or moderate (e.g., mood swings, nausea, insomnia, excitability, irritability, depression, hand tremors, headaches, nightmares), but on occasion can be severe and potentially life threatening (e.g., hallucinations, fever, severe autonomic nervous system overactivity, cognitive difficulties, blackouts, and DTs).2,3 Approximately 6 percent of hospitalized patients with alcohol problems experience withdrawal symptoms while hospitalized, and roughly 10 percent of these patients develop DTs.1
- Unrealized potential of screening and preventive treatment: Most hospitals do not proactively screen patients for excessive alcohol use, despite the fact that inhospital treatment (monitoring vital signs and administering intravenous fluids, sedatives, and other medications) can prevent or reduce withdrawal symptoms.2 For example, at Christiana Care, the vast majority of patients in alcohol withdrawal were not identified until they experienced severe symptoms.
Description of the Innovative ActivityChristiana Care nurses screen all admitted patients for alcohol withdrawal using a validated risk assessment tool; if a patient screens positive, the nurse administers a second questionnaire that evaluates severity of withdrawal symptoms. As necessary, physicians initiate algorithm-based treatment using an established order set that specifies the dosage and timing of medication based on the patient's symptom severity. The algorithm also guides ongoing symptom reassessment, vital sign monitoring, and medication dose adjustment. Key program elements include the following:
- Hospital-wide screening: As part of the patient intake process, nurses administer the Alcohol Withdrawal Risk Assessment to every new adult patient using the validated tool called the Alcohol Use Disorders Identification Test (AUDIT-PC).4 A modified version of the World Health Organization AUDIT tool, the AUDIT-PC includes five simple questions (listed below) followed by a selection of multiple-choice responses with an associated point value. A score of five or more points indicates risk of alcohol withdrawal:
- “How often do you have a drink containing alcohol?” (If the patient replies “never,” the assessment is complete.)
- “How many drinks containing alcohol do you have on a typical day when you drink?”
- “How often during the last year have you found that you were not able to stop drinking once you started?”
- “How often during the last year have you failed to do what was normally expected from you because of drinking?”
- “Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?”
- Additional questions for at-risk patients: Nurses ask patients who screen positive on the AUDIT-PC for additional information, such as the date and time of their last drink, history of withdrawal-related seizures or DTs, and use of Ativan, Valium, Xanax, or sleep aids.
- Assessment of withdrawal symptoms: For those screening positive, the nurse also administers the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar).5 This scale evaluates the severity of withdrawal symptoms, including nausea and vomiting; tremors; paroxysmal sweats; anxiety; agitation; tactile, auditory and visual disturbances; headache; and (dis)orientation. Scores can range from 0 to 67, which are further categorized into mild, moderate, or severe. (See next bullet below for more details.)
- Algorithm-driven treatment and monitoring: The nurse notifies the attending physician of all patients who screen positive on the Alcohol Withdrawal Risk Assessment (AUDIT-PC) and of their CIWA-Ar score. Depending on the patient's scores and the physician's clinical judgment, the physician may initiate an order set outlining precaution and treatment algorithms based on internally developed care management guidelines.
- Precaution algorithm: Nurses follow the precaution algorithm if the patient’s baseline score on the CIWA-Ar is in the mild range (8 or below). This algorithm directs nurses to readminister the CIWA-Ar every 8 hours for 72 hours. If reassessment yields a score of 9 or above (moderate to severe range), the nurse then initiates the treatment algorithm (see bullet below). With each CIWA-Ar administration, the nurse also documents the patient's vital signs and the Riker Sedation Agitation Scale (SAS) score.6
- Treatment algorithm: The treatment algorithm specifies administration of Ativan (an antianxiety medication approved for the treatment of alcohol withdrawal symptoms) every 4 hours for patients within the moderate and severe CIWA-Ar ranges. One hour after administering the Ativan, the nurse reassesses the patient using the CIWA-Ar to determine whether a subsequent dose or dose adjustment is needed. The nurse again documents the patient's vital signs and SAS score. This assessment (CIWA-Ar, vital signs, SAS) continues at least every 4 hours and more frequently if Ativan is being administered. Ativan dosing may also be available every hour as needed for both the precaution and treatment algorithms.
- Physician notification if problems arise: The nurse notifies the attending physician if any of the following problems arise with a patient: vital signs out of the normal range; CIWA-Ar score greater than 8 for two consecutive hours despite receiving maximally ordered around the clock and as needed medication dosages or greater than 10 despite receiving more than 4 mg of Ativan in any 1 hour; unsafe patient behavior; or symptoms suggestive of DTs (hallucinations or auditory, visual, or tactile disturbances). In these instances, patients either continue to receive care on the medical/surgical unit or are moved to the intensive care unit (ICU) at the physician’s discretion.
- Postdischarge treatment and counseling: Before discharge, a health system social worker or member of a pilot peer-to-peer intervention program offers and assists patients who are receptive, the opportunity to participate in community-based alcohol treatment and counseling.
Context of the InnovationChristiana Care Health System is an 1,100-bed tertiary care facility serving Delaware and nearby areas of Pennsylvania, Maryland, and New Jersey. Each year, Christiana Care receives more than 160,000 emergency department visits at its two campuses (913-bed Christiana Hospital and 241-bed Wilmington Hospital) and admits roughly 56,000 patients, nearly 600 of whom experience alcohol withdrawal symptoms. The impetus for this program came from several adverse events in which patients and staff were injured when individuals not identified as problem drinkers subsequently experienced alcohol withdrawal symptoms. A multidisciplinary team analysis of these events led Christiana Care leaders to develop a standardized process to identify and treat patients with alcohol dependence before severe withdrawal symptoms manifest.
ResultsThe program helped in identifying more patients with alcohol withdrawal and in preventing development of DTs in those diagnosed. It also improved care for patients with DTs, as evidenced by shorter length of stay (LOS), less use of restraints, and fewer transfers to the ICU.
Moderate: The evidence consists of pre- and post-implementation comparisons of key outcome measures, including the percentage of patients diagnosed with alcohol withdrawal, the percentage of patients with alcohol withdrawal developing delirium tremens, length of stay, restraint use, and intensive care unit transfers of patients with delirium tremens.
- Slightly more alcohol withdrawal diagnoses: The percentage of patients diagnosed with alcohol withdrawal increased slightly, from 0.83 percent of admitted patients before implementation (first through third quarter of 2009) to 0.9 percent afterward (fourth quarter of 2009 through the third quarter of 2010).
- Fewer cases of DTs: During this same time period, the percentage of alcohol withdrawal patients who developed DTs decreased from 24.2 percent before implementation to 20.8 percent afterward.
- Better care for DTs patients: DTs patients experienced better outcomes after the implementation of the program when compared with patients before implementation of the program, including shorter average LOS (which decreased from 12.75 to 9.35 days), less use of restraints (from 60.4 to 44.4 percent of patients), and fewer transfers to the ICU (from 21.6 to 15.0 percent of patients). Disruptions caused by patients suffering from DTs also decreased after implementation of the program.
Planning and Development ProcessSelected steps included the following:
- Workgroup assignment: Health System leaders charged a previously existing alcohol withdrawal workgroup to create algorithms for identifying and treating patients in alcohol withdrawal. Members included advanced practice nurses, registered nurses, physicians, pharmacists, information technology (IT) staff, and performance improvement staff. The workgroup met approximately every 2 weeks, with several key members meeting more frequently.
- Background research: The workgroup conducted an extensive review of the literature on alcohol withdrawal screening and treatment, including available screening tools.
- Pilot test of assessment tool: The workgroup conducted a pilot test of a basic risk assessment questionnaire on three units for three months. When the pilot ended, nurses from one unit asked if they could continue using the questionnaire.
- Identification of tools, creation of care management guideline: The workgroup identified validated tools to screen for withdrawal risk (the AUDIT-PC) and estimate symptom severity (CIWA-Ar). The workgroup also created a care management guideline and order set for all disciplines based on a preexisting clinical practice guideline used by nurses to guide the treatment of patients experiencing alcohol withdrawal.
- Integration of tools and order set into electronic systems: One year after implementation, the IT department added the tools and order set into the health system’s information systems.
- Clinician training: The workgroup introduced the tools and algorithms to nurses through existing inservice training. The workgroup made presentations to physicians, physician assistants, and nurse practitioners during grand rounds devoted to alcohol withdrawal, and held lectures for particular clinician groups (such as surgeons and hospitalists).
- Focus group and additional training: The workgroup led a focus group with nurses to assess their understanding of alcohol withdrawal symptoms and treatment and to determine their comfort in using the assessment tools and algorithms. After the focus group, the workgroup held a second nursing inservice training on several units.
Resources Used and Skills Needed
- Staffing: Program development and operations require no new staff, as existing staff integrate these activities into their everyday responsibilities.
- Costs: Program development required some staff time, as outlined in the Planning and Development section. The costs of ongoing program operations are negligible.
Funding SourcesChristiana Care Health System
Tools and Other ResourcesThe Alcohol Use Disorders Identification Test (AUDIT) manual, which includes the AUDIT screening tool, is available at: http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is available at: http://umem.org/files/uploads/1104212257_CIWA-Ar.pdf.
Information about the Riker Sedation Agitation Scale (SAS) can be found in: Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999; 27(7):1325-1329. [PubMed]
Getting Started with This Innovation
- Ensure leadership support: Health system leaders should fully support the activities of the workgroup charged with developing the screening and treatment algorithms. At Christiana Care, a multidisciplinary team convened after a serious patient safety outcome was presented to the patient safety committee, which had representation from senior leadership. The results from this analysis prompted the committee to give the workgroup the authority to engage staff and physicians in the effort and, ultimately, to implement the new approach.
- Introduce whole program at once: Design and implement a comprehensive program, rather than just an assessment or order set alone.
- Educate nurses not to be judgmental: Nurses should be educated to present the assessment tool to patients in a nonjudgmental way, emphasizing their interest in the patient’s care and well-being and desire to ensure the best possible outcomes.
Sustaining This Innovation
- Gather data and provide feedback: Use the organization’s information system to track key outcomes from the program, including whether nurses administer the screening tool to all patients and the number of patients diagnosed with and treated for alcohol withdrawal. Sharing performance information with nurses helps ensure that they continue to administer the tool over time. In addition, health system leaders will be more likely to support the program if they see data demonstrating its ability to identify and treat more at-risk patients.
Contact the InnovatorTerry Horton, MD, FACP
Chief, Division of Addiction Medicine
Christiana Care Health System
4755 Ogletown Stanton Road
Ammon Bldg. 2E70
Wilmington, DE 19801
Ruth Mooney, PhD
Nursing Research Facilitator
Christiana Care Health System
4755 Ogletown Stanton Road
Newark, DE 19718
Jo Melson, FNP
Christiana Care Health System
501 W. 14th Street
Wilmington, DE 19801
Innovator DisclosuresDr. Horton, Dr. Mooney, and Ms. Melson have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesChristiana Care Health System. Identifying problem drinkers on admission improves care. Focus. August 26, 2010. Available at: http://issuu.com/christianacare/docs/focus-8-26-2010.
1 Christiana Care Health System. Identifying problem drinkers on admission improves care. Focus. August 26, 2010. Available at: http://issuu.com/christianacare/docs/focus-8-26-2010.
Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999; 27(7):1325-1329. [PubMed]
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Original publication: October 26, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: September 11, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: September 13, 2012.
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