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Identifying Patients "At Risk" for Alcohol Withdrawal Syndrome and a Treatment Protocol.

Abstract: Alcohol abuse and alcohol dependence are common problems. It is estimated that more than 10 million Americans have problems with alcohol dependence that adversely affect their lives and the lives of their families. Many of these patients, if hospitalized, have the potential to experience symptoms of alcohol withdrawal. Major alcohol withdrawal symptoms may include seizures and the development of delirium tremens. Obtaining an alcohol consumption history is a critical component to identifying patients at risk and determining the appropriate treatment plan for potential alcohol withdrawal. A protocol was established for identifying and treating patients at risk for alcohol withdrawal. The initiation of the treatment protocol is history- and symptom-based; treatment is symptom-triggered on the basis of frequent objective assessments. The purpose of the protocol is to prevent and control withdrawal symptoms without heavily sedating or hindering a patients' neurological assessment.

Introduction

The chronic consumption of alcohol is a widespread problem that accounts for many health-related illnesses and deaths each year. Alcohol dependence affects an estimated 10 million-20 million Americans and 15-20% of primary care and hospitalized patients.[2,3,9] Alcohol is involved in 10% of all deaths in the United States.[7] The mortality rate for those who consume six or more drinks per day is 50% higher than the rate in matched controls.[8] Patients who experience alcohol withdrawal symptoms often have a more complicated hospitalization, an extended length of stay, and increased utilization of intensive care and other services.[10] Mortality rates for delirium tremens have been estimated to range from 5 to 15%.[4] Because alcohol dependency and abuse are common problems and failure to recognize patients early may lead to symptoms of withdrawal and eventually delirium tremens, it is essential that the healthcare team screens all patients, identifies all patients who are at risk, and treats patients before a life-threatening situation arises. This article describes the systematic approach that was instituted at the Medical College of Georgia Hospital and Clinics (MCG) for screening, assessing, and managing patients who were identified as "at risk" for alcohol withdrawal.

Patient Assessment

At our institution, patients at risk for alcohol withdrawal syndrome often were unidentified until withdrawal symptoms became severe and admission to the intensive care unit (ICU) was necessary. There was no standard of care for managing patients identified as alcohol abusers. Also, a wide variety of symptom management methods were used.

Assessing a patient to determine risk for alcohol withdrawal is an interdisciplinary healthcare team effort. The nurse and physician should approach this as a team.[6] A history of alcohol consumption should be collected because it is crucial to determining a treatment plan for each patient. A nurse can assess the patient's alcohol consumption upon the patient's admission interview with the patient and the family. Nurses assist by taking a very detailed alcohol consumption history, which includes the type and amount of alcoholic beverages consumed per week. The nurse also collects specific information about the date and time of the last alcohol consumption because the patient may need to undergo a surgical procedure and require analgesics or other anesthetic agents. Documenting the time of the last consumption helps identify the expected window for the development of withdrawal symptoms. The nurse also collects information on alcohol-related injuries or alcohol-related illnesses within the past year Hospital admissions for unrelated conditions and elective surgery can be precipitating events for the cessation of alcohol consumption and may unexpectedly result in alcohol withdrawal syndrome.

The data gathered by the nursing team complement the data collected by the physician in the initial patient history and physical examination. From the data gathered, the team looks for clues that might identify the patient for risk of alcohol withdrawal syndrome. For example, a patient with a history of previous alcohol withdrawal and alcohol withdrawal-related seizures would be at high risk for alcohol withdrawal. Independent assessments by the physician and the nurse are important, but the entire medical care team must make it a priority to identify patients at potential risk for alcohol withdrawal. After a patient has been assessed for potential withdrawal and treatment, a plan for each individual patient can be outlined. The plan includes discussing the protocol with the patient, family, physicians, nurses, case managers and social workers and referring the patient to a treatment program.

Uncomplicated Alcohol Withdrawal Syndrome

Alcohol withdrawal may begin from within 8 hours to several days after the last drink. Signs and symptoms of uncomplicated withdrawal include tremor, a craving for alcohol, insomnia, vivid dreams, anxiety, irritability, tachycardia, and sweating. Peak signs and symptoms usually occur within 24-36 hours, and symptoms either abate or progress within 48 hours of onset. Factors that place a patient at greater risk of progressing to complicated withdrawal include a history of long duration of alcohol intake; large amounts of alcohol intake (including binge drinking); a prior history of alcohol detoxification or withdrawal seizures; prior delirium tremens; symptoms of alcohol withdrawal at the time of presentation; or an acute coexisting medical illness.[11]

Delirium tremens usually occurs within 1-4 days of the onset of withdrawal and peaks within 72 hours after drinking cessation. Delayed onset of delirium tremens may be as long as 7 days. Signs and symptoms of delirium tremens include clouding of sensorium, profound autonomic hyperactivity (increased temperature, tachycardia, and hypertension), hallucinations, and seizures. If alcohol withdrawal-related seizures occur, they usually occur within the first 24 hours of withdrawal symptoms.

Alcohol Withdrawal Protocol

The Medical College of Georgia Hospital and Clinics (MCG) is an academic institution with a fluctuating house staff and physicians with limited experience. Management of alcohol withdrawal in patients was unstructured and inconsistent. To reduce the incidence of patients experiencing delirium tremens or symptoms of severe withdrawal and thus reduce morbidity and improve patient outcomes, an interdisciplinary team was created. The team had two major goals: (1) to create and establish a mechanism for identifying patients at risk for alcohol withdrawal syndrome early in their hospital stay, and (2) to establish a standardized approach for assessing and treating patients identified as being at risk for alcohol withdrawal. The interdisciplinary team comprised representatives from the nursing subspecialties (surgery, neurology, psychiatry, intensive care, and advanced practice medicine), physicians (neurology, pulmonary/critical care, trauma, and psychiatry), and the pharmacy. A neurologist served as the team leader, and a critical care neuroscience clinical nurse specialist and pharmacist acted as facilitators.

Initially the team identified the key problems as the lack of routine identification of patients at risk for withdrawal and the lack of a formal monitoring process for patients at risk. Also, there was no standard approach to prophylaxis and treatment of alcohol withdrawal symptoms, and there were no ICU admission criteria for patients with severe withdrawal symptoms.

The team developed a protocol with three major components:

* A standardized initial nursing assessment form

* An "alcohol withdrawal severity flowsheet" for patient assessment

* A standardized order set for the "alcohol withdrawal prophylaxis protocol" utilizing lorazepam (Ativan).

Initial Screening

All patients admitted to the hospital, including critical care and general medical-surgical patients, receive an initial nursing assessment within 8 hours of admission and a history and physical examination from a physician within 24 hours. If there is a history of alcohol consumption, a specific alcohol consumption history is taken and a CAGE questionnaire is administered. The CAGE questionnaire is a mnemonic for four questions that are asked by either the physician or the nurse:

* Have you felt you should Cut down on your alcohol consumption?

* Have people Annoyed you by criticizing your drinking?

* Have you felt Guilty about your drinking?

* Have you ever had a drink first think in the morning (Eye opener) to steady your nerves or get rid of a hangover?

This brief questionnaire is a reliable and reproducible tool for assessing patients and their risk for alcohol withdrawal symptoms.[1,5,6,7,10]

Patients with a "yes" response to any of the CAGE questions are placed on the alcohol withdrawal prophylaxis protocol and evaluated with the alcohol withdrawal assessment scale every 4 hours. Those patients with three or four "yes" responses on the CAGE are at high risk for alcohol withdrawal. These patients are assessed every 4 hours for at least 48 hours. As part of the protocol, a physician may decide to have the nurse administer an initial dose of 1 mg of lorazepam if there is a strong history of alcohol consumption and a high CAGE score (Fig 1).

[Figure 1 ILLUSTRATION OMITTED]

Alcohol Withdrawal Prophylaxis Protocol Orders

The standard orders provide for supportive care measures including the administration of thiamine, fluid and electrolyte management, and maintenance of a calm, quiet environment. A nurse evaluates the patient every 4 hours by using a structured withdrawal severity assessment scale to objectively quantify the severity of withdrawal symptoms. The scale is based on the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-A).[9,10] The simplification of the CIWA-A scale makes assessment by the nursing staff members quicker and easier. Categories that the nurse assesses include heart rate, blood pressure, temperature, diaphoresis, tremor, nausea/vomiting, agitation, sleeplessness, orientation, hallucinations, and seizures. Each symptom receives a rating based on its severity (Fig 2). Heart rate, blood pressure, and temperature are more heavily weighted with this scale to provide more emphasis on symptoms of autonomic hyperactivity and recognize the patients who are more likely to need additional monitoring and more aggressive treatment in a critical care setting. At the time of initial evaluation, a withdrawal severity assessment scale score is given. If the patient scores above 10 on the assessment scale, the physician is contacted and dosing of lorazepam is initiated--the dose is based on the symptom severity score (Table 1).
Fig 2. Alcohol Withdrawal Severity Assessment Flowsheet

[ILLUSTRATION OMITTED]

Heart Rate

1-Heart rate 80-100 beats/min
2-Heart rate 100-130 beats/min
5-Heart rate [is greater than] 130 beats/min

Blood Pressure

1-Systolic 150-175 mmHg
2-Systolic 176-200 mmHg
5-Systolic [is greater than] 200 mmHg

Temperature

1-37.5-38 C (99.5-100.4 F)
2-38-38.5 C (100.4-101.3 F)
5- [is greater than] 38.5 C (101.3 F)

Diaphoresis

1-Mild, barely visible
2-Moderate
3-Marked, clothes or bedding soaked

Tremor (Arms extended, fingers spread)

1-Tremor felt by examiner, but not visible
2-Mild visible tremor
3-Marked visible tremor

Nausea/Vomiting (N/V)

1-Nausea only
2-Vomiting once, not exceeding twice in 8 hrs
3-Frequent vomiting, "dry heaves"

Agitation

1-Activity increased
2-Restless, "fidgety"
3-Restless, pacing, thrashing in bed

Sleeplessness

1-Awake during night (2-3 times)
2-Awake half or all of the night

Orientation

1-Detached, decreased sensation,
 vague orientation
2-Vague about present illness, infrequent
 disorientation
3-Detached, disoriented

Hallucination

1-Tactile only, visual only, auditory only,
 and not agitated by them
2-Tactile & visual, tactile & auditory, or
 visual & auditory but not related (i.e. what
 is seen, is not heard, & vice-versa)
3-Auditory and visual hallucinations are related
 (i.e. what is seen is also heard)

Seizures

Document presence (+) or absence (-).
Notify physician immediately of seizure
activity.

If a sign or symptom is not present, score is "0"
Table 1. Low-Dose Lorazepam Dosing Schedule

Withdrawal Severity Lorazepam
Assessment Score Dose, mg

>20 3
15-19 2.5
10-14 2
6-9 1
1-5 0


Lorazepam was selected as the benzodiazepine of choice because it is available both as an intravenous and an oral medication and it does not require preparation or refrigerated storage on the nursing unit (as does chlordiazepoxide). Lorazepam also has a predictable onset of action and has no active metabolites, thus resulting in relatively predictable duration of action.[14] Lorazepam is the only medication used in the treatment protocol; dosing is determined from the score the patient receives on the severity assessment scale; and it is administered orally or intravenously depending on the clinical situation. Scoring on the severity assessment scale is repeated 15-30 minutes after administration of each lorazepam dose. A repeat dose is allowed every hour if the score remains elevated. Assessment scores, lorazepam doses, and respiratory status are monitored and recorded by the nurse on the "alcohol withdrawal severity flowsheet" (Fig 2). The physician can order use of a "high-dose" lorazepam schedule if the patient has an inadequate response to the initial dosing schedule (Table 2). Patients with an assessment score of 25 points or greater, withdrawal seizures, severe aggression, or hallucinations not responding to lorazepam are admitted to the intensive care unit. When the patient is in the intensive care unit, the protocol is discontinued and the patient is managed according to his or her individual medical needs. Once the withdrawal severity assessment score is less than 6, the frequency of the assessment decreases to hourly for 2 hours and then every 2 hours. If the assessment score remains less than 6 for more than 6 hours, monitoring is decreased to every 4 hours for the next 48 hours. If all severity scores within a 24-hour period are less than 5, the protocol is discontinued after consultation with the physician.
Table 2. High-Dose Lorazepam Dosing Schedule

Withdrawal Severity Lorazepam
Assessment Score Dose, mg

>20 4
15-19 3.5
10-14 3
6-9 2
0-5 0


Utilizing this symptom-triggered approach provides much better care for the patient than the standard-dose, standard-interval regimen commonly used. The use of a severity assessment score allows dosing based on the severity of symptoms, and the patient is closely monitored after each dose of lorazepam. This approach results in less total drug use and is as responsive as fixed-dose schedules.[12]

Healthcare Team Education

An educational program for nursing, pharmacy, and medical staff members was conducted prior to hospital-wide implementation of the protocol. A 30-minute video reviewed the rationale for the protocol, the steps in patient screening, the procedure for ordering the monitoring protocol for the patient at risk, dosing of lorazepam, communication among caregivers, and chart documentation. Each member of the medical staff received a memorandum from the physician team leader describing the protocol, reviewing the standard orders and nursing procedures, and giving several case study examples. Team members conducted random retrospective chart reviews of all patients admitted to MCG at 3, 6, and 10 months after implementation of the protocol to assess the effectiveness of the screening process and proper identification of patients. Utilization of the standard orders was reviewed on all patients identified as "at risk" for alcohol withdrawal syndrome. Results of the evaluation were used to target further education and performance improvement activities.

Discussion

Institution of a protocol for assessing patients at risk for alcohol withdrawal syndrome and a standardized treatment protocol has demonstrated several advantages. Patients who are at risk for alcohol withdrawal syndrome are being identified and monitored earlier. The retrospective chart review showed that 88% of patients identified at high risk for withdrawal (e.g., CAGE score of 3-4 or history of prior alcohol withdrawal) who were monitored and treated according to the protocol did not develop severe withdrawal symptoms. The chart review also showed that of all patients who were identified as "at risk" for alcohol withdrawal, 75% were monitored through assessments and never received a lorazepam dose. Nurses are an integral part of the assessment and treatment protocol. The standardized orders allow nurses to give lorazepam doses based on the severity scale without further orders from physicians. Physicians are contacted when the withdrawal assessment is instituted, when the first dose of lorazepam is indicated, if a change from the low dose to the high dose schedule is warranted, and if the withdrawal assessment score is greater than or equal to 25. The patient is monitored more closely and treated more appropriately with nurses and physicians working together to manage their alcohol withdrawal symptoms.

Throughout the implementation of the protocol, four major issues were encountered. First, some individual physicians resisted the implementation of the protocol. Patients would be identified as "at risk" for developing alcohol withdrawal by nursing personnel, but the physician would refuse to order the protocol. Instead, physicians would order other medication regimens such as chlordiazepoxide (Librium), clonidine hydrochloride (Clonidine), or haloperidol (Haldol). Physicians ordering their own treatment deviated from the hospital practice standard as the protocol is approved by the Medical Executive Committee.

Second, because of the fluctuation of incoming house staff physicians, education about the protocol could easily be missed. Therefore, a continual educational effort has been made by the physician team leader to inservice all new house staff physicians during their orientation.

Third, nursing personnel noted inconsistencies in the frequency of the alcohol withdrawal severity assessment, in particular, that patients were not being assessed at the ordered interval or after lorazepam dosing. Thus, patients might not be appropriately assessed for symptoms of early alcohol withdrawal or they might be receiving less lorazepam than their clinical situation requires. In an effort to improve these inconsistencies, inservices were periodically provided.

The final issue was that physicians were ordering scheduled and PRN doses of lorazepam in addition to following the protocol. The use of scheduled and PRN doses of lorazepam were not based on objective assessment criteria and sometimes resulted in the patient being heavily sedated.

All four of these issues have led to confusion in patient management. In an attempt to decrease inconsistencies, increase compliance with the protocol, and clarify patient management, results of the retrospective chart audits are shared quarterly with hospital administration, departments, and staff.

Summary

The development and implementation of a protocol for identifying and treating patients who are "at risk" for developing alcohol withdrawal was an interdisciplinary process that improved working relationships between team members, heightened the awareness of the comorbidity of alcohol withdrawal, provided a consistent treatment plan, and facilitated nurses becoming an active partner in patient treatment. When the protocol is followed, patients are managed consistently, nursing time is conserved, and withdrawal symptoms are prevented or controlled. Based on the issues that we encountered, we believe that ongoing education of current and new staff members is essential to realizing the maximum benefit of the alcohol withdrawal assessment and treatment protocol. Future plans include continual monitoring of the utilization and effectiveness of the protocol and the development of a treatment protocol for patients with alcohol withdrawal in the intensive care unit setting.

References

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[3.] Eckardt MJ, Harford TC, Kaelber CT: Health hazards associated with alcohol consumption. JAMA 1981; 246: 648-666.

[4.] Erwin WE, Williams DA, Speir WA: Delirium tremens. So Med J 1998; 91; 425-432.

[5.] Ewing JA: Detecting alcoholism: The CAGE questionnaire. JAMA 1984; 252: 1905-1907.

[6.] Israel Y, Hollander O, Sanchez-Craig M et al: Screening for problem drinking and counseling by the primary care physician-nurse team. Alcohol Clin Exp Res 1996; 20(8): 1443-1450.

[7.] Kithcens JM: Does this patient have an alcohol problem? JAMA 1994; 272(22): 1782-1787.

[8.] Klatsky AL, Armstrong MA, Friedman GD: Alcohol and mortality. Ann Intern Med 1992; 117: 646-654.

[9.] Mayo-Smith MF: Pharmacological management of alcohol withdrawal: A meta-analysis and evidence-based practice guideline. JAMA 1997; 278: 144-151.

[10.] Patch PB, Phelps GL, Cowan G: Alcohol withdrawal in a medical-surgical setting: The `too little, too late' phenomenon. Medsurg Nurs 1997; 6(2): 79-89, 94.

[11.] Saitz R: Recognition and management of occult alcohol withdrawal. Hospital Practice 1995; 15: 49-58.

[12.] Saitz R, Mayo-Smith MF, Roberts MS et al: Individualized treatment for alcohol withdrawal syndrome: Results of a randomized clinical trial. J Amer Med Assoc 1994; 272: 519-523.

[13.] Spies CD, Neuner B, Neuman T: Intercurrent complications in chronic alcoholic men admitted to the intensive care unit following trauma. Inten Care Med 1996; 22: 286-293.

[14.] Watling SM, Fleming C, Casey P, Yanos J: Nursing-based protocol for treatment of alcohol withdrawal in the intensive care unit. Amer J Crit Care 1995; 4: 66-70.

Questions or comments about this article may be directed to: J. Ned Pruitt II, MD, Associate Professor of Neurology and Director of Undergraduate Neuroscience Education, Medical College of Georgia Hospital and Clinics, Augusta, GA 30912.

Lori Schumacher, MS RN, is a Clinical Nurse Specialist in Neurosciences at Memorial Health University Medical Center, Savannah, GA.

Marjorie Phillips, MS RPh FASHP, is the Quality Improvement and Drug Information Center Pharmacist at the Medical College of Georgia Hospital and Clinics, Augusta, GA.

Copyright [C] 2000 American Association of Neuroscience Nurses 0047-2603/00/3203/00158$1.25
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Author:Schumacher, Lori; Pruitt, J. Ned II; Phillips, Marjorie
Publication:Journal of Neuroscience Nursing
Geographic Code:1USA
Date:Jun 1, 2000
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