Evaluating the benefits of using a scoring system to aid management of alcohol withdrawal at an NHS district general hospital
Aims
To assess whether incorporating the Clinical Institute Withdrawal Assessment of Alcohol scale, revised (CIWA-Ar) into hospital guidelines for managing alcohol withdrawal increases staff confidence and knowledge of managing this condition.
Methods
Two recent cases were identified where patients with alcohol withdrawal developed delirium tremens despite prescription of regular chlordiazepoxide. We considered whether these patients required more frequent review and dosing of chlordiazepoxide. We conducted two surveys of healthcare staff – one before introducing the CIWA-Ar score, and one following introduction – to assess the benefits of using this scoring system to guide management. Staff surveyed included nurses and doctors of all grades. Areas surveyed were the A&E department, the medical assessment unit, and the gastroenterology ward.
Results
We received 75 responses in our first survey and 42 in our second survey. 96% of respondents had previously managed alcohol withdrawal. 55% were aware of the CIWA-Ar score prior to its introduction, and 22% had used it previously in other hospitals. 13% of doctors and 20% of nurses did not feel confident in identifying the signs and symptoms of withdrawal. 44% of staff did not know how to adequately dose or administer PRN chlordiazepoxide. There was also variability in what staff felt to be the maximum daily dosage of chlordiazepoxide.
Following introduction of the CIWA-Ar score, 74% of staff had used the scoring system to manage patients. Of those that had used it, 97% felt that it helped them monitor the progress of withdrawing patients. 90% felt that it helped them identify patients who were deteriorating despite regular chlordiazepoxide. Of all staff surveyed, 93% felt that the CIWA-Ar score helped them prescribe and administer adequate PRN doses of chlordiazepoxide.
Staff identified several downsides to using the scoring system. Several respondents felt that filling in the score took too long. The score was also felt to be subjective. Furthermore, staff identified that alternative factors (eg sepsis) could lead to a higher CIWA-Ar score.
Conclusions
Our initial survey indicated that alcohol withdrawal is commonly encountered by staff working in acute medical areas, but confidence and knowledge of management could be improved. Use of the CIWA-Ar score increased staff confidence in monitoring, identifying deterioration, and managing this patient group.
Conflict of interest statement
There are no conflicts of interest to declare.
- © Royal College of Physicians 2017. All rights reserved.
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