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The clinical nurse as an agent of change.

An adult female is rushed to the medical intensive care unit (MICU) from a general medicine unit due to a blood pressure of 68/44 mm Hg. The patient is barely conscious. How did this patient go from the agitated, hypertensive state typical of alcohol withdrawal to being pale, barely conscious, and hypotensive? Situations such as this may occur when patients are not treated appropriately for alcohol withdrawal symptoms. Alcohol withdrawal is a very serious, potentially fatal condition with symptoms such as agitation, tremors, tachycardia, hypertension, nausea and vomiting, and seizures (Gortney et al., 2016). If the withdrawal is not treated, it can lead to delirium tremens (DTs), which can cause patient death due to seizures or dysrhythmias from electrolyte imbalance (Gortney et al., 2016). Continuous observation by clinical nurses offers a unique perspective to patient care. Clinical nurses can take an active role as agents of change. Clinical nurses' assistance in implementing an interprofessional practice change for care of patients at risk from or experiencing alcohol withdrawal is described.

Literature Review

PubMed MeSH terms used initially were ethanol, withdrawal, and protocol; humans, English language, and the years 2005-2015 were included. CINAHL terms were nurse education and alcohol withdrawal.

Riddle, Bush, Tittle, and Dilkhush (2010) noted 1 in 4 patients admitted to general hospitals meet the diagnostic criteria for alcohol dependence. Three sources of information were used to build the protocol: anecdotal information from colleagues combined with the article by Repper-DeLisi and colleagues (2008) from similar hospitals, and physiology of alcohol abuse and withdrawal. These sources supported building the symptom-based treatment and the CAGE questionnaire (Castells & Furlanetto, 2005).

Improvement Needs/ Group Oversight

Patients who use alcohol regularly may be at risk for alcohol withdrawal, even if they do not believe they are dependent on this substance. Withdrawal symptoms can start 2-72 hours from time of last consumption; thus hospitalization is a prime opportunity for withdrawal to appear (Gortney et al., 2016). A nurse in the MICU was concerned about patients admitted during alcohol withdrawal. She noticed a lack of standardized treatment in the work environment, and knew from talking to her colleagues that nurses and providers could be better educated about patients at risk for alcohol withdrawal as well as its sequelae. She believed if a platform could be built to better educate staff, as well as support them and patients with a standard pathway to treat alcohol withdrawal, then severe withdrawal symptoms could be prevented.

Motivated by her experiences with this patient population, the MICU nurse took her concerns about treatment of alcohol withdrawal to a MICU collaborative meeting and discovered others shared her concern. The result of this meeting was the formation of a multidisciplinary group of 41 professionals, including hospitalists, pharmacists, psychiatrists, clinical nurses, and nurse managers dedicated to the development of a standardized alcohol withdrawal pathway.

This group was hoping to show standardized treatment would decrease patients entering alcohol withdrawal DTs or requiring ICU care due to alcohol withdrawal. Psychiatry staff were tasked with developing a protocol for medication use as well as a system for identifying critical symptoms of alcohol withdrawal. The general medicine hospitalists collaborated in this endeavor and were responsible for teaching the new pathway to their residents and interns. Pharmacists built the order sets needed to order and deliver the medication. Nurse managers ensured staff awareness and compliance throughout their respective units by providing the staff and funding to develop unit experts on alcohol withdrawal. Nurse managers also made it a point to round on patients with the alcohol withdrawal diagnosis to ensure the protocol was being followed. Performance management specialists were involved in tracking the effectiveness of the pathway. The MICU nurse recruited a colleague, and together they developed nursing-specific education. They presented the Alcohol Withdrawal Pathway to hospital-wide committees for further development. These two nurses, in collaboration with nurse managers, enlisted superusers. These super-users were experienced nurses who volunteered to work with the alcohol withdrawal group, to educate their respective units, as well as to troubleshoot any issues arising during implementation of the pathway. Once the group expanded to super-users, these clinical nurses had valuable input into how to realistically and effectively implement the withdrawal pathway, how to provide accurate documentation, how to track patients on the pathway, and how to educate clinical colleagues who would be using the pathway. Even though the super-users were all clinical nurses, this was an important position to develop across multiple floors because nurses from the emergency department, general medicine floors, and surgical floors all had different experiences and issues with the project rollout.

Continuous Quality Improvement Model

One of the first steps a nurse can undertake when trying to implement change is to identify the question, including the correct population, intervention, comparison to other groups, and expected outcomes. This technique is otherwise known as the PICO format (Hastings & Fisher, 2014). For this scenario, the question would read along these lines: In alcohol-dependent patients over age 18, what is the effect of a standardized, scheduled treatment on patients who will potentially or are already showing signs and symptoms of alcohol withdrawal, compared with our prior practice? Once the question and goals were identified, the team was named the Alcohol Withdrawal Work Group (AWWG).

Quality Indicators and Data Collection

Quantitative data were not collected for this particular project. This article is intended as an informative piece describing how clinical nurses can initiate change in their work environment. Nursing super-users, nurse managers, physicians, and pharmacists involved in the AWWG monitored the correct application of the protocol by rounding on diagnosed patients and with staff caring for them. Monthly AWWG meetings were held during the first year of the practice change to monitor successes, assess for problems, and offer new solutions. Anecdotal evidence from rounds with clinical nurses seemed to support the new protocol; nurses perceived patients were being treated more appropriately for withdrawal symptoms and they valued having a clear treatment plan.

Data collection has been challenging. A change in the health system's documentation during the project's initiation made it difficult to compare data from the two systems. Members of the AWWG were not focused originally on data collection, and the intervention was started before questions could be written and data collected. For example, nurses cannot be surveyed on their comfort caring for withdrawing patients before the pathway because all staff have received teaching to the pathway, thereby not eliciting how the nurses felt before the rollout. The authors advise nurses working on quality improvement projects to consider data collection before the project is in advanced stages. Determining types of data to collect, necessary methods, and their implications would have been a great benefit for this project. Also, all team members should have a clear, direct conversation about who has the rights to publish which kind of data. Examples of possible data to collect include staff comfort working with withdrawing patients, ICU transfers/Rapid Response calls related to alcohol withdrawal, length of hospital stay, staff satisfaction with the pathway, and number of calls to hospital security related to alcohol withdrawal.

Evaluation and Action Plan

A change is less likely to occur if it is of little importance to the institution or its members. The team began by focusing primarily on general medicine and surgical trauma, as these units received the majority of alcohol withdrawal patients at this hospital at the time. Patients with an admitting diagnosis of alcohol withdrawal were an obvious concern, but the group looked at other populations at risk for alcohol use and withdrawal as well: patients admitted after a motor vehicle crash or with seizure or respiratory compromise, or found unconscious for unknown reasons at home. Clinical nurses' suspicion proved correct, as it was discovered quickly that none of the units or physicians had a standard protocol for treating the patient with alcohol withdrawal. Decisions often were made based on the patient's previous withdrawal course in the hospital or the physician's prior success with a certain process, often without considering if that method would be effective for the patient now. The issue of alcohol withdrawal was relevant to the health system because of the absence of a standardized pathway. Within the entire health system, one hospital linked to the university, and two other hospitals in the local community, each party had its unique way of treating alcohol withdrawal. This led to some confusion among staff who had rotations or jobs at more than one facility in the system.

With all disciplines together, the AAWG determined the requirements for each department in order to proceed. For example, pharmacists recommended patients who receive lorazepam (Ativan[R]) every 4 hours should have increased monitoring to prevent oversedation; physicians agreed as they wanted increased monitoring for symptom control, but clinical nurses and nurse managers recognized the labor demand of such a change. A collaborative decision was made that once patients needed lorazepam at that interval or required symptom assessment every 2 hours, they would require increased monitoring and be reclassified to stepdown status. Clinical nurses and their managers were pleased with this modification, which would devote increased staff to provide more effective care for intensely monitored patients. Nurses expressed their concerns and participated in decision making. Physicians and pharmacists established the desired level of monitoring. Nurses and physicians collaborated on how and where to document total medication administered so information was readily available for physician monitoring and nurse documentation. Clinical nurses, managers, and physicians from the intermediate and stepdown units collaborated with their ICU partners to determine a standard outcome in each patient's care that would require transfer. From one person's idea for change came a team effort for lasting transformation.

In the authors' health system, two community hospitals already had a standard treatment method for withdrawing patients. One community hospital used the Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA), while the other used a CIWA-based algorithm; the academic medical center was without a standard protocol. The natural question posed to the AWWG was, "Why not just use CIWA?" It seemed to be a convenient and trusted solution. However, a psychiatrist on the AWWG offered literature about the lack of CIWA validation for use in the medical-surgical setting and with patients with anything other than uncomplicated alcohol withdrawal (Hecksel, Bostwick, Jaeger, & Cha, 2008). The same study in Massachusetts General Hospital also identified difficulty in training nurses to use CIWA with consistent results. Members of the AWWG perceived their facility was comparable to Massachusetts General Hospital in numbers of beds and yearly patient admissions, so they recommended against using CIWA. With that decision, the group was ready to pilot the changes.

The first year after implementation, the group met monthly to discuss effectiveness of the pathway, unforeseen issues, and complex patient events. Once members assessed anecdotal evidence and agreed nurses and physicians were using the pathway effectively, the group met less frequently and the pathway was expanded to other patient care areas in the hospital. Super-users were solicited from new patient care areas and trained by super-users from the first implementation. Further efforts at disseminating information included presentation at a system-wide evidence-based practice symposium and poster presentation at the annual Patient Safety and Quality Conference. The AWWG was runner-up for 2012 Advance for Nurses Best Nursing Team. Changes and collaboration continued; members of the work group added their input to building the hospital's new electronic charting system.

Results and Limitations

Starting a practice change when multiple other changes also were occurring in the institution may have had a negative effect on the success of pathway adoption. Information regarding the pathway often was met with responses similar to, "Another thing I have to learn?" or "When do we have to start this?" A change in the documentation system in June made it difficult for providers to order the pathway. In addition, new residents soon arrived who were unfamiliar with the hospital's newly established practice. The pathway was not ordered as easily.

Nursing Implications

The authors' motivation behind this article is that staff at any level can organize change in their institutions. Often, clinical practitioners may perceive changes are being done to them; instead, nurses in the AWWG found they were a part of the change. The original idea for a practice change regarding alcohol withdrawal came from a concerned nurse; the project continues with clinical nurses involved at every interval. The hospital now has a unified method of caring for a complex patient population. By eliminating variables in care, the AWWG has eliminated confusion among providers and nurses, providing a safer setting for staff and patients. This experience can be duplicated in any medical-surgical setting.


A hospital-wide, interprofessional work group was formed to address concerns about patients withdrawing from alcohol. Regular meetings and collaboration produced a nursing care plan and a provider order set specific to the diagnosis of alcohol withdrawal. Super-users were clinical nurses who educated their colleagues; eventually super-users were named on every unit as resources. Commitment to the practice was reinforced by attending physicians, pharmacists, and nurse managers. Now a successfully adopted practice change, this protocol may move from the project hospital into the entire health system.


Castells, M.A., & Furlanetto, L.M. (2005). Validity of the CAGE questionnaire for screening alcohol-dependent inpatients on hospital wards. Revista Brasileira de Psiquiatria, 27(1), 54-57.

Gortney, J.S., Raub, J.N., Patel, R, Kokoska, L., Hannawa, M., & Argyris, A. (2016). Alcohol withdrawal syndrome in medical patients. Cleveland Clinical Journal of Medicine, 83(1), 67-79.

Hastings, C., & Fisher, C.A., (2014). Searching for proof: Creating and using an actionable PICO question. Nursing Management, 45(8), 9-12.

Hecksel, K.A., Bostwick, J.M., Jaeger, T.M., & Cha, S.S. (2008). Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clinic Proceedings, 83(3), 274-279.

Repper-DeLisi, J., Stern, T.A., Mitchell, M., Lussier-Cushing, M., Lakatos, B., Fricchione, G.L., ... Bierer, M. (2008). Successful implementation of an alcohol-withdrawal pathway in a general hospital. Psychosomatics, 49(4), 292-299.

Riddle, E., Bush, J., Tittle, M., & Dilkhush, D. (2010). Alcohol withdrawal: Development of a standing order set. Critical Care Nurse, 30(3), 38-47.

Victoria Eads, BSN, BA, RN, SRNA, is Student Registered Nurse Anesthetist, Duke University Nurse Anesthesia Program, Durham, NC.

Gregory Maruzzella, MSN, RN, is Staff Nurse, Medical Intensive Care Unit, Duke University Hospital, Medicine Unit, Durham, NC.
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Title Annotation:Continuous Quality Improvement
Author:Eads, Victoria; Maruzzella, Gregory
Publication:MedSurg Nursing
Date:May 1, 2016
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