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A1484 - Clinical Institute Withdrawal Assessment (CIWA) Protocol: Misunderstandings, Misuse, and Misadventures
Author Block: C. Chen1, C. Thompson2, M. J. Leveno3; 1Pulmonary and Critical Care, UT Southwestern, Dallas, TX, United States, 2Parkland Hospital, Dallas, TX, United States, 3Pulmonary, University of Texas Southwestern Medical Center, Dallas, TX, United States.
Rationale
Patients with alcohol use disorder are at risk of developing alcohol withdrawal syndrome if not adequately managed. In patients with active medical conditions, the signs and symptoms of alcohol withdrawal are difficult to recognize. Benzodiazepines have long been a mainstay in the treatment of alcohol withdrawal as they reduce the likelihood of progression to severe symptoms. The Clinical Institute Withdrawal Assessment (CIWA) was devised in the 1980s to objectively measure severity of alcohol withdrawal symptoms, and the revised system, CIWA-Ar, is widely utilized today. CIWA-Ar was intended for patients solely undergoing treatment for alcohol withdrawal, but it has been widely adopted in the inpatient setting for patients admitted for medical diagnoses who have concurrent alcohol use disorder. We hypothesized that providers and ancillary staff poorly understand the limitations of CIWA-Ar, resulting in inappropriate patient selection and poor adherence, which may contribute to undertreatment and intensive care (ICU) admission.
Methods
A survey of 124 providers at an academic, tertiary-care hospital was conducted to assess frequency of ordering the CIWA-Ar protocol, their confidence in assessing CIWA-Ar scores, and their functional knowledge. A similar survey of 101 bedside nurses was also performed. Their anonymous responses were assessed for correlation between level of training/years of experience, frequency of use, and functional knowledge. The electronic medical record was queried for inpatient hospital encounters associated with a CIWA-Ar protocol order between February 1, 2015, and August 19, 2015. A total of 1102 encounters were identified, 230 of which were associated with a primary admission diagnosis of alcohol withdrawal. These cases were reviewed to assess for adherence to the prescribed CIWA-Ar protocol. Of the 1102 encounters, 220 were randomly selected to review for appropriate patient selection for protocol use.
Results
Neither providers nor ancillary staff had good functional knowledge of the CIWA-Ar protocol, and a minority were able to identify all components of the CIWA-Ar score. This knowledge deficit was not associated with years of training or experience. Of the 1102 CIWA-Ar protocol-associated encounters, only 50% of patients were appropriate candidates for protocol use. The CIWA-Ar protocol was adequately followed by nursing in approximately 10% of patients. There was insufficient data to assess if poor adherence increased the likelihood of transfer to the intensive care unit.
Conclusion
Providers and ancillary staff have poor understanding of the CIWA-Ar protocol and its limitations. Patients are often inappropriately selected, and there is poor adherence to the protocol.