Management of alcohol withdrawal including the Symptom triggered CIWA score

Transcription

1 Management of alcohol withdrawal including the Symptom triggered CIWA score Classification: Policy Lead Author: Ruth Brown Alcohol specialist Nurse Additional author(s): Hailey Pennington Authors Division: Gastroenterology Unique ID: 185TD(P)66 Issue number: 6 Expiry Date: Dec Who should read this document? Key Messages Background & Scope Policy Treatment Pathways Flow chart for colour coded pathways based on CIWA-Ar Score For all Pathways Uncontrolled Withdrawals Poor English, Confused, Delirious or Psychotic Patients... 7 Delirium Tremens... 7 Elderly or Liver Disease... 7 Patients who are nil by mouth... 8 Withdrawal Seizures... 8 Transfer of patients Vitamins Prophylaxis against Wernicke- Korsakoff s Syndrome Vitamin Prophylaxis regimes Explanation of terms & Definitions References and Supporting Documents Roles and responsibilities Appendices Appendix 1 - CIWA-Ar Appendix 2 - Alcohol Withdrawal Audit Appendix 3 Care Flow Chart Policy Implementation Plan... Error! Bookmark not defined. 13 Monitoring and Review... Error! Bookmark not defined. 14 Endorsement... Error! Bookmark not defined. 15 Screening Equality Analysis Outcomes... Error! Bookmark not defined. Page 1 of 18

2 1 Who should read this document? This document is for all staff caring for patients who are at risk of alcohol withdrawal 2 Key Messages Overall symptom triggered dosing is associated with significantly lower doses of benzodiazepines and with shorter treatment duration without an increase in the incidence of seizures or DT s 9 RCP 2009). The RCP ( 2009) also concluded from their research that despite using less doses of Chlordiazepoxide with symptom- triggered treatment compared with a fixed- dosing regime, the former regimen were not associated with an increase in the severity of withdrawal during treatments as indicated by the non-significant differences in the number and amounts of as- needed. The rationale of using medication in patients with alcohol withdrawal is to provide relief of subjective symptoms, to prevent serious complications of withdrawal such as seizures and delirium tremens (DT s) and to achieve this with the minimal use of medication. In the UK practice, benzodiazepines are the most commonly used agents with Chlordiazepoxide and Diazepam favoured in many places (RCP 2009) This policy advocates the use of Chlordiazepoxide as the first level treatment of alcohol withdrawal symptoms (AWS), in a symptom triggered manner. Patients must be medicated at the RIGHT time, with the RIGHT drug and The RIGHT dose to control withdrawal and keep patients comfortable without over sedating. 3 Background & Scope Alcohol misuse and alcohol related problems, especially binge drinking and alcohol related liver diseases (ALD), are major public health concerns. In 2006/7, alcohol misuse cost the UK economy 25.1 billion Pounds. Of this, the NHS expenditure was 2.7 billion pounds. In 2008, 78% of the costs were incurred as hospital based care (Moriarty et al 2010). Although alcohol use and abuse are common among general hospital inpatients, many patients are inadequately assessed and treated for alcohol withdrawal (Repper-Delisi 2008). Many protocols for the treatment of alcohol withdrawal have been established. Most studies of their use indicate that implementation of a protocol improves patient outcomes (Repper-Delisi et al. (2008) and Daeppen Page 2 of 18

3 JB, Gache P, Landry U et al (2002)). The research conducted by Repper- Delisi et al. (2008), identifies that timely assessment and staff education can shift prescription patterns, increase patient monitoring, reduce costs associated with alcohol withdrawal and create a safer more caring environment for the patient and reduces the risk to staff and other patients being cared for on the unit and to staff working on the unit. In accordance with Trust Values patient care is at the centre of everything we do, therefore we must provide the best possible care to all patients attending Salford Royal NHS Foundation Trust. It has been noted that there is a large variation in local practice for the management of alcohol withdrawal. Opinions differ over the appropriate benzodiazepine detoxification regime and the appropriate vitamin supplementation. This guidance is being introduced to normalise the treatment received by patients who are alcohol dependent and ensure adequate levels of vitamin supplementation. The Royal College of Psychiatrists Working Party highlighted several components that appear to be critical for the development of a successful hospital alcohol strategy. This includes widely available protocols for the pharmacotherapy of detoxification (Royal College of Physicians 2001). Alcohol withdrawal syndromes occur when the blood alcohol level fallsbelow a certain threshold in patients with a long history of alcohol consumption (Yim A. and Wiener S. 2009). Some patients are not troubled by alcohol withdrawal whilst 40% will develop an acute withdrawal syndrome upon stopping or significantly reducing alcohol intake (Brown and Fletcher 2008). It is clear from the research and the massive problem alcohol is causing the health service, as a Trust we must ensure we are providing the most patient centred, evidenced based and timely appropriate care possible. This policy is being introduced to guide clinicians to provide the best evidence based assessment and care to patients suffering from Alcohol Withdrawal Syndrome (AWS). 4 Policy The CIWA-Ar (see Appendix 1) allows the effects of acute alcohol withdrawals to be measured using a ten point scoring system (Sullivan et al 1989). It enables staff to measure the severity of withdrawal, track progress and recognise escalating agitation early. This information can be used to modify and individually tailor an individual s sedation regime as their condition changes and to intervene early if the score rises sharply, suggesting that there may be a risk of patient deterioration. The categories assessed using the CIWA-Ar score are as follows: 1. AGITATION ANXIETY AUDITORY DISCTURBANCES HEADACHE NAUSEA AND VOMITING SWEATING TREMOR 0-7 Page 3 of 18

4 8. TACTILE DISTURBANCES VISUAL DISTURBANCES ORIENTATION 0-4 CIWA-Ar GREATER than 15 indicates SEVERE withdrawal CIWA-Ar 8-15 indicates MODERATE withdrawal CIWA-Ar LESS THAN 8 indicates MINIMAL to MILD withdrawal Assess and rate each of the ten criteria using CIWA-Ar form Appendix). Each criterion is rated on a scale form 0-7, except for orientation and clouding of the sensorium which is rated on scale 0-4. Add up the scores of the ten criteria. This is the total CIWA-Ar score for the patient at that time. Always use CIWA-Ar as an adjunction to clinical judgment 5 Treatment Pathways The recommended pathway is dependent on the category of withdrawal based upon the patient s CIWA- Ar score: CIWA-Ar score Category of withdrawal 1-4 Follow White Pathway 5-15 Mild- Follow Yellow Pathway Moderate Follow Orange Pathway >25 Severe- Follow Red Pathway Page 4 of 18

5 5.1 Flow chart for colour coded pathways based on CIWA-Ar Score Observe Patient Score = 1-4 MILD Score = 5-15 MODERATE Score = SEVERE Score > 25 4 Hourly: CIWA Score, BP, Pulse, Sats and RR. If Score Increases move on to appropriate Pathway >25 4 Hourly: CIWA Score, BP, Pulse, Sats and RR. If Score Increases move on to appropriate Pathway >25 2 Hourly: CIWA Score, BP, Pulse, Sats and RR. If Score Increases move on to appropriate Pathway >25 1 Hourly: CIWA Score, BP, Pulse, Sats and RR. 10mg Chlordiazepoxide at each 4 Hourly Observations 20mg Chlordiazepoxide at each 2 Hourly Observations 30mg Chlordiazepoxide at each 1 Hourly Observations Score of 1-4 on 4 Occasions Score of 1-4 on 4 Occasions When Score < 16 Treat as Mild Withdrawal and follow Yellow Pathway When Score < 26 Treat as Moderate Withdrawal and follow Orange Pathway FINISH FINISH Page 5 of 18

6 5.2 For all Pathways Treat patient as an individual using symptom triggered approach move through pathways appropriately, if a person becomes medically well they can be discharged they do not have to complete the pathways. Ensure the patient has been referred to Alcohol Specialist Nurses if available It is imperative to ensure the patient is assessed frequently and on time. Using appropriate pathway to reassess. If concerned always seek medical advice alert ASN if available and follow policy guidelines for management of alcohol withdrawal. Inform medical staff if the patient is administered 240mgs of Chlordiazepoxide in a 24 hrs period. Inform medical staff if the patient becomes over sedated Successful detoxification treatment is not purely pharmacological we must ensure adequate support and appropriate management of withdrawals assess motivation, aftercare arrangements and suitability for discharge. If Chlordiazepoxide becomes short in supply to liaise with pharmacy and ASN with regards to the use of alternatives. CONTINUE FLOW CHART UNTIL PATIENT IS ON WHITE PATHWAY AND HAS SCORED 4 OR LESS, 4 TIMES THEN DISCONTUINUE 6 Uncontrolled Withdrawals Uncontrolled withdrawal describes patients on the red pathway with ongoing significant symptoms of alcohol withdrawal despite 1 hourly CIWA and 30mgs of chlordiazepoxide use. It may also describe patients with severe symptoms of alcohol withdrawal and a history of regular very large alcohol intake who are likely to or have required higher doses of chlordiazepoxide to control alcohol withdrawal. Please liaise with an upper tier doctor (ST3 or above) or a consultant before considering the following. Use increased doses of Chlordiazepoxide mgs 2 hourly PRN titrated against CIWA score Diazepam oral or IV as an alternative to Chlordiazepoxide (2.5mgs of Diazepam = 5 mgs of Chlordiazepoxide) Page 6 of 18

7 If these medications are commenced please add recording of respiratory rate alongside clinical observations every 15 minutes until CIWA less than Poor English, Confused, Delirious or Psychotic Patients For these patients the CIWA scale is inappropriate as the patient will not be able to score on Anxiety, orientation and clouding of sensorium, tactile, auditory and visual disturbances It may be more appropriate to assess physical symptoms objectively and use a FIXED reduction regime immediately Day 8am 12pm 6pm 10pm 1 20mg 20mg 20mg 20mg 2 20mg 20mg 20mg 20mg 3 20mg 20mg 20mg 20mg 4 20mg 15mg 15mg 15mg 5 15mg 10mg 10mg 10mg 6 10mg 5mg 5mg 5mg 7 5mg - - 5mg 6.2 Delirium Tremens Please liaise with an upper tier doctor (ST3 or above) or a consultant before considering: Increased dose of Chlordiazepoxide mg 2 hourly PRN or Lorazepam 2-4 mgs 2 hourly IM if psychotic symptoms persist, use haloperidol 0.5 mgs 6 hourly IM If these medications are commenced please add: recording of respiratory rate alongside clinical observations every 15 minutes until CIWA less than 20 and at least for 1 hour after administration of Lorazepam, diazepam or higher Chlordiazepoxide doses 6.3 Elderly or Liver Disease In the frail elderly population or those with established liver disease consider a lower starting dose of Chlordiazepoxide. Shorter acting benzodiazepines, e.g. Oxazepam can be used if necessary though will need to be ordered specifically from pharmacy seek advice from an upper tier doctor or consultant, Established hepatic encephalopathy would be a relative contraindication for benzodiazepines these patients should be reviewed by an upper tier doctor or consultant before starting a formal withdrawal regime. Page 7 of 18

8 Remember that even patients with significant liver disease may need larger doses to control withdrawal symptoms. For most patients start the usual standard regime but watch carefully for toxicity or encephalopathy (e.g. drowsiness and flapping tremor) Where signs of toxicity occur reduce the dose and consider reducing the frequency of chlordiazepoxide. All patients with signs of toxicity should be reviewed by an upper tier doctor or consultant. 6.4 Patients who are nil by mouth Patients who are at high risk of alcohol withdrawal who are nil by mouth should have an alternative route of medication made available to prevent severe withdrawal symptoms developing. Give lorazepam sublingually at the equivalent dose to the patient s usual chlordiazepoxide. Lorazepam tablets should be placed under the tongue and allowed to dissolve. If the patient has a very dry mouth the lorazepam tablet can be dissolved in a few drops of warm water, drawn up in a syringe and placed buccally. Where there are severe withdrawal symptoms PRN lorazepam SL 0.5-1mg can be used between standard doses. Consider Lorazepam 2-4mg for uncontrolled withdrawal or delirium tremens. These patients should be reviewed by an upper tier doctor or consultant In the frail elderly and patients with established liver failure standard doses should be used with reductions as described in section 1.3 Benzodiazepine equivalences Chlordiazepoxide Diazepam Oxazepam Lorazepam (SL) 10mgs 5mgs 15mgs Withdrawal Seizures Alcohol withdrawal seizure is a medical emergency and medical help should be sought immediately. Initial treatment either: rectal Diazepam 10mgs every 5 minutes until controlled or intravenous Diazepam titrated against symptoms, beginning with 5-10mg Continue anti-epileptic medication if already prescribed and established Page 8 of 18

9 Do not instigate anti-epileptic medication treatment as prophylaxis for alcohol withdrawal seizures since it will take several days to achieve therapeutic levels and is therefore likely to be ineffective. For prophylaxis of alcohol withdrawal seizures use appropriate doses of Chlordiazepoxide as described in section Transfer of patients Unless clinically indicated transfer of patients should be avoided until patients with symptomatic withdrawal are under control i.e. are scoring 10 or below on the CIWA scale before they are transferred between ward areas. This helps to reduce paranoid thoughts and confusion and limit incidents of violence and aggression. Where patients are transferred with a CIWA score of 10 or more the receiving ward needs to ask the following: What the patients latest CIWA score is. What medications have they to control withdrawals. Has the patient required 1 to 1 nursing or had any management issues. They can then ascertain the best placement on the ward for the patient preferably in an observable area but away from stimulus. 7 Vitamins Prophylaxis against Wernicke- Korsakoff s Syndrome Wernicke Korsakoff s syndrome is a manifestation of thiamine (vitamin B 1 ) deficiency. It is characterized by vision changes, ataxia and impaired memory. Many alcohol dependent patients are at risk of developing Wernicke s/korsakoff s syndrome due to thiamine deficiency. It is a disabling condition and can be prevented by ensuring vitamin prophylaxis is given to all at risk patients. In recent years the use of parenteral vitamins has reduced, due to concerns over anaphylactic reactions. As a result there have been increases in the number of cases of Wernicke s/korsakoff s syndrome. The following points are important. The risk of anaphylaxis is low less than 1 in 1,000,000 for IV infusion and lower still for the IM route. The maximum amount of thiamine absorbed from 10mg oral does is between 4.3 and 5.6mgs in healthy volunteers and in malnourished alcoholics, absorption may be as low as 1.5 mgs per dose (5).It is important to note that absorption is not increased with larger doses of thiamine as absorption of oral thiamine is medicated by an active, Page 9 of 18

10 saturable transport mechanism therefore the oral route will not be adequate to replace thiamine in a significant proportion of these patients. Replacement of thiamine stores needs to be as rapid as possible and high circulating levels of thiamine are needed for passive diffusion into the CNS. 7.1 Vitamin Prophylaxis regimes All patients who drink alcohol above recommended limits should be considered for vitamin prophylaxis Low risk of Wernicke s Thiamine 50 mg QDS orally for 10 days. (continue even if discharged) Low risk and nil by mouth At risk (malnourished, poor diet, weight loss) Incipient Wernicke s (confusion in 90%, sometimes with ataxia, memory disturbance, eye muscle paralysis) 1 pair of Pabrinex ampoules (1 x No 1 ampoule plus 1 x No 2 ampoule) in 100ml sodium chloride 0.9% over 30 minutes once daily intravenously for three days. 1 pair Pabrinex ampoules (1 x No ampoule plus 1 x No 2 ampoule) in 100ml of sodium chloride over 30 minutes intravenously TDS for 3 days. 2 pairs of Pabrinex ampoules ( 2 x No 1 ampoule plus 2 x No 2 ampoule ) in 100ml of sodium chloride over 30 minutes intravenously TDS for 3 days After discharge thiamine should be given at full doses for 10 days only. 8 Explanation of terms & Definitions Definitions Alcohol Ethanol (ethyl alcohol) is the main psychoactive ingredient in alcoholic drinks. By extension, the term alcohol can be used interchangeably with ethanol, and to describe an alcoholic drink. Alcohol Dependence (Condition) A cluster of behavioural, cognitive, and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent will keep drinking despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations. Page 10 of 18

11 Alcohol Specialist nurse This is a hospital based nurse; please contact team with regards to their roles and responsibilities. The team will be able to provide knowledge and support for patients and staff. Alcohol Withdrawal Syndrome (AWS) AWS is a collection of symptoms experienced by people who stop drinking after a prolonged period of heavy consumption. Alcohol depresses nerve function and, when this effect is suddenly withdrawn, there is over excitation of the central, peripheral and autonomic nervous systems leading to confusion and agitation, abnormally heightened perception and autonomic hyperactivity. Alcohol Withdrawal Syndrome can be further sub-categorised. Uncomplicated Alcohol Withdrawal This results from autonomic hyperactivity. Symptoms are typically seen within 6 to 8 hours of the last drink and may well develop before the blood alcohol level falls to zero (depending on tolerance). Symptoms outlined below may vary in severity, commonly peaking at hours usually subsiding by hours (Brown and Fletcher 2008). Tremulousness (note: hands, tongue or eye lids) Sweating Fever with or without infection Nausea, vomiting, retching Anxiety Agitation Irritability Anorexia Insomnia Tachycardia Mild Systolic Hypertension Hallucinations Sometimes auditory (frequently accusatory or derogatory voices) and sometimes visual hallucinations occur in otherwise clear sensorium. The sensorium is sensory components of the brain and nervous system that deal with the receiving and interpreting of external stimuli. This is unlike the case for delirium tremens where sensorium is diffusely impaired. Delirium Tremens (DTs) DTs occur in only about 5% of patients undergoing alcohol withdrawal but accounts for the highest morbidity and mortality (5-20% mortality in inappropriately managed patients) with appropriate management mortality reduced to 1-5%. Onset of DTs is 2-5 days (most common at 2-3 days) following cessation and represents a medical emergency. Page 11 of 18

12 Characteristic Symptoms Auditory and visual illusions and hallucinations Severe tremor in hands and body Confusion and disorientation Delusions (may become withdrawn) Agitation Clouding of consciousness Profound symptoms of autonomic over activity Tachycardia > 100/min Fever, with or without infection, temperature >38.3 C (Yim and Wiener 2009). Most cases of DTs can be prevented by prompt initiation of appropriate treatment. A patient is at high risk of delirium tremens if: Previous history of severe withdrawal/ delirium Tachycardia >100bpm Marked withdrawal symptoms Intercurrent infection e.g. chest infection/ UTI High temperature (Brown and Fletcher 2008) Alcohol Related Seizures This includes tonic-clonic seizures that usually occur within hours of alcohol cessation and may develop before the blood level has fallen to zero. Fits are rare beyond 48 hours following cessation. Individuals may have several seizures. Very rarely status epilepticus occurs. Identification of those at risk History of previous withdrawal seizures History of epilepsy Predictors of Withdrawal Severity Number of previous detoxifications Quantity and duration of drinking A high blood alcohol level without signs of intoxication or A high blood alcohol level with signs of withdrawal Concurrent use of sedative-hypnotics Coexisting medical problems Clinical Institute Withdrawal Assessment for Alcohol The policy recommends the use of the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). The Clinical Institute Withdrawal Assessment (CIWA-Ar) scale is a validated 10-item assessment tool that can be used to quantify the severity of the AWS, and to monitor and medicate patients throughout withdrawal. It determines the initial severity of withdrawal, response to treatment, and the need for additional medication. It measures 9 categories of symptoms on a scale of 0-7 and one symptom (clouding of sensorium) as 0-4. Page 12 of 18

13 Severity of Symptoms by Score: < 8= mild symptoms 8-15= Moderate Symptoms >15= Severe Symptoms The CIWA-Ar score is determined hourly, and medication is administered only when the score is 8 or above. Compared to previous fixed dose Chlordiazepoxide regimes, this is a symptom triggered approach which provides an individualised regimen. Reviews of literature and research conclude symptom-triggered dosing was associated with significantly lower doses of benzodiazepines than fixed-dosing, with shorter treatment duration, and importantly without an increase in the incidence of seizures or delirium tremens (RCP 2009). 9 References and Supporting Documents Brown A. and Fletcher A. (2008) Imperial College Healthcare Hospital In- Patient Alcohol Guidelines. Imperial College. London. Cook CCH et al.br J Hospital Med 1997; 57(9):461-5 Daeppen JB, Gache P, Landry U et al (2002) Symptom triggered vs. fixed schedule doses of benzodiazepine for alcohol withdrawal. Arch Intern Med Vol (162) pp Daly, Chris (2002) Management of Alcohol withdrawal ( issue number 1) Document NO.- 185TD (P) 66 Salford Royal Hospital Trust. Ketchan Katherine, and Asbury William (2000) Beyond the influence understanding and Defeating Alcoholism 10: 155. Moriarty et al (2010), Alcohol Related Disease. Meeting the Challenge of Improved Quality Care and Better Use Resources. A Joint Paper on Behalf of the British Society of Gastroenterology, Alcohol Health Alliance UK and the British Association for Study of the Liver. Repper-Delisi J., et al (2008) Successful Implementation of an Alcohol- Withdrawal Pathway in a General Hospital. Psychosomatics Vol 49(4) pp Royal College of Physicians (2001) Alcohol- Can the NHS afford it? RCP: London Sullivan JT., Sykora K., Schneiderman J., Naranjo CA and Sellars EM (1989). Assessment of Alcohol Withdrawal: The Revised Clinical Institute Withdrawal Instrument for Alcohol Scale (CIWA-Ar) British Journal of Addiction 84 pp Teaching Module: Managing alcohol withdrawal with CIWA-AR (ttp:/ Yim A. and Wiener S. (2009) Delirium Tremens. Emedicine. accessed 14/10/14 10 Roles and responsibilities The use of CIWA-Ar scoring to initiate symptom triggered approach to medication following the algorithm will be monitored via clinical audits ( see example in Appendix 2) at least once every three years and the results reviewed by Divisional Governance committees Page 13 of 18

14 The Alcohol specialist nurse (ASN) will ensure the policy is uploaded onto the Trust s Document Management System for Trust Wide use Ward managers will be involved in the implementation of this policy ; following a teaching conducted by ASN Teaching sessions will be held with allocated link nurses on wards to give them knowledge to help cascade this information. Copies of the policy will be sent to each consultant to ensure they have a working knowledge of the policy and can relay this information to their junior colleagues. Ward Pharmacist and ASN will be responsible for cascading knowledge of the policy through pharmacy colleagues. Page 14 of 18

15 11 Appendices Appendix 1 - CIWA-Ar Clinical Dimension Question and/or Observation Nausea / Vomiting Ask Do you feel sick? Observe for vomiting Tremor Arms extended and fingers spread apart Paroxysmal Sweats Observation Anxiety Ask Do you feel nervous? Observation Agitation Observation Tactile Disturbances Ask Have you any itching, pins and needles sensations, burning or numbness, or do you feel bugs crawling on or under Date & Time Date & Time Date & Time Score Range = No nausea, no vomiting 1 = Mild nausea, no vomiting 2 = Intermittent nausea with dry heaves 3 = Constant nausea, frequent dry heaves And vomiting 0 = No tremor 1 = Not visible but can be felt fingertip to Fingertip 4 = Moderate with patients arms extended 7 = Severe even with arms not extended 0 = No sweat visible 1 = Barely perceptible sweating, palms Moist 4 = Beads of sweat obvious on forehead 7 = Drenching sweats 0 = Normal activity 1 = Mildly anxious 4 = Moderately anxious or guarded so Anxiety is inferred 7 = Equivalent to acute panic states as seen In severe delirium or acute Schizophrenic reactions 0 = Normal activity 1 = Somewhat more than normal activity 4 = Moderately fidgety and restless 7 = Paces back and forth during most of the Interview or constantly thrashes about 0 = None 1 = Very mild itching, pins & needles, Burning or numbness 4 = Moderately severe hallucinations 7 = Continuous hallucinations Page 15 of 18

16 your skin? Observation Auditory Disturbances Ask Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing you? Are you hearing thins you know are not there? Observation Visual Disturbances Ask Does the light appear to be bright? Is the colour different? Does it hurt your eyes? Are you seeing anything that is disturbing you? Are you seeing things you know are not there? Observation Headache, Fullness in head Ask Does your head feel different? Does it feel like there is a band around your head? Orientation and clouding of sensorium Ask What day is this? Where are you? Who am I? 0 = Not present 1 = Very mild harshness or the ability to Frighten 4 = Moderately sever hallucinations 7 = Continuous hallucinations 0 = Not present 1 = Very mild sensitivity 4 = Moderately severe hallucinations 7 = Continuous hallucinations 0 = Not present 1 = Very mild 2 = Mild 4 = Moderately severe 7 = Extremely severe 0 = Orientated and can do serial additions 1 = Cannot do serial additions or is uncertain About date 2 = Disorientation for date by no more than 2 calendar days 3 = Disorientation for date by more than 2 Calendar days 4 = Disorientation for place / person Total Dose recommended for this score (For chlordiazepoxide) Dose Administered Initials Page 16 of 18

17 Appendix 2 - Alcohol Withdrawal Audit Audit proposal: Trust wide retrospective case note/isoft audit based on patients that showed signs of alcohol withdrawal during their admission. ASN will be able to determine which patients were showing signs of alcohol withdrawal and therefore which patient group to draw the sample from. Due to the high volume of names received per day a random sample of 50 taken from one week would provide a good snapshot of practice. Draft Audit Tool - Alcohol Withdrawal Audit Audit ID: Hospital Site: Yes No Not Documented 1) Had this patient been screened for signs of Alcohol withdrawal on this admission? 2) Had the patient started on the Alcohol withdrawal ICP? 3) Had the LD questionnaire been completed? 4) Were the following bloods requested? FBC LFT U&Es 5a) Was the patient s CIWA-Ar Score assessed? 5b) Was this prior to the initiation of treatment for alcohol withdrawal? 6a) Was any treatment given for Alcohol withdrawal? 6b) If yes was this appropriate to the patients CIWA-Ar score (please refer to algorithm of the AWS guidelines)? 7) Were observations carried out as required, as appropriate to the treatment pathway (please refer to algorithm) Page 17 of 18

18 Appendix 3 Care Flow Chart Page 18 of 18