Development and Implementation of an Evidence-Based Alcohol Withdrawal Order Set. Kathleen Lenaghan MSN, RN-BC

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1 Development and Implementation of an Evidence-Based Alcohol Withdrawal Order Set Kathleen Lenaghan MSN, RN-BC 1

2 2 Genesis Medical Center Davenport, Iowa

3 Objectives Identify the process of developing and implementing a new alcohol withdrawal order set in an acute care hospital. Describe the new evidence-based order set. Describe outcomes of using the new order set. 3

4 Case Study 46 year old man Admitted to the neuroscience unit with a small subdural hematoma Blood alcohol level of 70 mg/dl on arrival Reports drinking two or three beers each day for many years 4

5 Development and implementation of order set 5 Identified the problem Referred to Nursing Research and Evidence- Based Practice Committee Formed a multidisciplinary team Surveyed nursing staff Reviewed current literature Developed new order set Presented to medical committees Computer documentation developed Educated nursing staff Monitored for appropriate use and outcomes

6 Alcohol withdrawal syndrome in hospitalized patients: review of literature Symptoms of alcohol withdrawal usually start in the first 24 hours of abstinence. If treated aggressively in early abstinence the most serious symptoms are less likely to develop. If not treated the patient suffers, care becomes more complex, and length of stay increases. 6

7 Alcohol withdrawal syndrome in hospitalized patients: review of literature Delirium tremens (DT) and seizures are the most serious responses to alcohol withdrawal. DT and seizure can be avoided by recognition and treatment of early withdrawal symptoms. Effective withdrawal treatment increases the likelihood the patient will follow through with substance abuse treatment. 7

8 Alcohol withdrawal syndrome in hospitalized patients: review of literature Patients at high risk for severe withdrawal symptoms should have treatment with medications in early abstinence whether or not withdrawal symptoms have developed. Patients with moderate or severe symptoms of withdrawal should be treated with medications. Patients at moderate risk should have medications based on withdrawal symptoms. 8 Benzodiazepines are the medication class of choice for treating alcohol withdrawal.

9 Order set Assessment with CIWA-Ar scale Vitamin and fluid replacement Benzodiazepine orders based on risk of severe withdrawal symptoms, age, and liver disease 9

10 Benzodiazepine orders High risk patients Scheduled benzodiazepines for three days Symptom triggered benzodiazepines based on CIWA-Ar score Medium risk patients Symptom triggered benzodiazepines 10

11 Choice of benzodiazepine Long acting benzodiazepines for most patients Intermediate acting benzodiazepines for patients over age 65 or with severe liver disease 11 All benzodiazepines ordered my mouth with instruction: May give IV if patient is not able to tolerate PO; may give IM if patient is not able to take PO and no IV access is available.

12 Safe use orders Call physician if CIWA-Ar score remains greater than 15 on two consecutive assessments. Monitor vital signs with each assessment and with medication administration. Omit any dose if patient is difficult to awaken, is showing signs of over sedation, is exhibiting marked ataxia, or has a respiratory rate less than 12. Notify physician if unable to arouse. 12

13 Outcomes 18 Patients with emergence of confusion, hallucinations, or disorientation Order set not used Order set used

14 Outcomes 14 Patients requiring constant observation for confusion related to alcohol withdrawal Order set not used Order set used

15 References Center for Substance Abuse Treatment. (2006). Detoxification and substance abuse treatment. Treatment Improvement Protocol (TIP) Series 45. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. Holbrook, A., Crowther, R., Lotter, A., Cheng, C. & King, D. (1999). Meta-analysis of benzodiazepine use in the treatment of acute alcohol withdrawal. Canadian Medical Association Journal, 160(5), Kosten, T. & O'Conner, P. (2003). Management of drug and alcohol withdrawal. The New England Journal of Medicine, 348(18),

16 References Mayo-Smith, M. (1997). Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline. Journal of the American Medical Association, 278(2) Mayo-Smith, M., Beecher, L., Fischer, T., Gorelick, D., Guillaume, J., Hill, A., et al. (2004). Management of alcohol withdrawal delirium: an evidence-based practice guideline. Archives of Internal Medicine, 164, McKay, A., Koranda, A. & Axen, D. (2004). Using a symptom-triggered approach to manage patients in acute alcohol withdrawal. Medsurg Nursing, 13(1), McKinley, M. (2005). Alcohol withdrawal syndrome: overlooked and mismanaged? Critical Care Nurse, 25(3),

17 References Reoux, J. & Miller, K. (2000). Routine hospital alcohol detoxification practice compared to symptom triggered management with an objective withdrawal scale (CIWA-Ar). The American Journal on Addictions, 9, Smith, M. (2003). The search for insight: clients' psychological experiences of alcohol withdrawal in a voluntary, residential, health care setting. International Journal of Nursing Practice 10, Sullivan, J., Sykora, K., Schneiderman, J., Naranjo, C. & Sellers, E. (1989). Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). British Journal of Addiction, 84,

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