Use of a modified Clinical Institute Withdrawal Assessment (CIWA) for symptom-triggered management of alcohol withdrawal syndrome

James Russell; Neal Richardson; Aglaja Dar

doi:10.7861/clinmedicine.15-3-s20

Aims

To investigate current shortcomings in the management of alcohol withdrawal syndrome, and to explore whether symptom-triggered prescribing of benzodiazepines could facilitate timely discharge and benefit patient safety.

Methods

The Clinical Institute Withdrawal Assessment (CIWA) is a validated tool for symptom-based prescribing of chlordiazepoxide in alcohol withdrawal, and is an alternative to traditional fixed-dose regimens, which may prolong length of stay for up to 5 days. A prospective analysis was undertaken of adult patients admitted to a London hospital with signs of alcohol withdrawal syndrome. A total of 40 cases were audited over a 3-month period. Re-audit was carried out following the introduction of a modified CIWA for use by staff in the accident and emergency department. CIWA uses a mixture of subjective and objective assessments to create an overall alcohol withdrawal score. This score is used to calculate an appropriate stat dose of chlordiazepoxide, which is given to the patient and adjusted regularly based on repeated scores. Adherence to the NICE guidelines on management of alcohol-use disorders was compared between both groups, as was overall length of stay.

Results

In the initial audit, 34 out of 40 patients met the NICE criteria for inpatient withdrawal management. The most common criteria for admission included history of seizures or delirium tremens. Six patients did not meet the criteria for inpatient withdrawal management and yet were admitted in order to complete fixed-dose regimens of chlordiazepoxide. Average length of stay in this group was 2 days (range 1–5 days). Following the introduction of CIWA, 31 cases were analysed using the same method. All patients in this group met the NICE criteria for inpatient withdrawal management, with 12 patients having a history of withdrawal seizures and 11 patients admitting to drinking more than 30 units per day. There were no patients admitted solely to complete fixed reducing courses of chlordiazepoxide.

Conclusions

Alcohol withdrawal syndrome can be managed safely with symptom-triggered prescribing of chlordiazepoxide, and CIWA is a simple tool that facilitates this. When used in the acute setting, CIWA prevents overtreatment and avoids unnecessary hospital admission. This may obviate the requirement for fixed-dose chlordiazepoxide and a one-size-fits-all approach to withdrawal management.