JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Alcohol withdrawal management in adult patients in a high acuity medical surgical transitional care unit: a best practice implementation project
Olga Sukhenko
1,2
1. University of California San Francisco Medical Center, San Francisco, USA 2. UCSF Center for Evidence-Based Patient and Family Care: an Affiliate Center of the Joanna Briggs Institute; University of California San Francisco Medical Center
Primary contact Olga Sukhenko [email protected]
Key dates Commencement date: September, 2014 Completion date: March, 2015
Executive summary Background Excessive alcohol consumption, a major health problem worldwide, affects about 6% of the United States population. Caring for patients with alcohol withdrawal syndrome (AWS) in a hospital ward presents complex physiologic and psycho-social challenges which are best met with evidence-based practices. An academic medical center in the United States has been experiencing an increase in patients with AWS. However, gaps in clinician knowledge and infrastructure supporting the management of these patients still existed. Objectives The aim of this project was to improve the continuity of care of patients undergoing alcohol withdrawal in a medical surgical high acuity transitional care unit by incorporating evidencebased practices, and thereby to positively impact on patient outcomes. Specific objectives were related to standardized assessments and pharmacologic management strategies.
doi: 10.11124/jbisrir-2015-2529
Page 314
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Methods The project used the Joanna Briggs Institute’s Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit tool for promoting change in health practice. A baseline clinical audit was conducted to assess compliance with best practices for managing AWS, which was followed by several interventions targeted at nurses and providers. A follow-up audit was conducted to assess compliance with the implemented strategies. The follow-up audit used the same evidence-based audit criteria as those used for the baseline audit. A non-probabilistic, convenience sampling approach was used. A sample size of 15 patients was used for both the baseline and follow-up audits. Results The baseline audit revealed a high compliance rate for four of the five audit criteria concerning risk assessment and pharmacologic strategies. There was sub-optimal compliance (53%) with the criterion regarding use of the Clinical Institute Withdrawal Assessment of Alcohol Scale (revised) (CIWA-Ar) scale to assess patients with alcohol withdrawal. After the interventions were implemented this criterion recorded an improvement to 100% compliance. None of the patients in the pilot were transferred to the intensive care unit (ICU) for reasons relating to alcohol withdrawal. Conclusions The outcomes of this project demonstrated alcohol withdrawal management can be safely undertaken outside the ICU when the patients are appropriately assessed and treated for the severity of their withdrawal symptoms. This new clinical program significantly impacted on continuity of care. Challenges were resolved using an interdisciplinary team approach. The project resulted in plans for further areas of work concerning alcohol withdrawal management, including adoption of similar approaches by other acute and transitional care units. Keywords acute care; alcohol abuse; alcohol symptoms; alcohol withdrawal; screening
Background Alcohol abuse has detrimental effects and the clinical care of patients undergoing alcohol withdrawal 1
is highly complex because it combines physical factors with psycho-social issues. According to the World Health Organization (WHO) Global Status Report on Alcohol and Health 2014, the highest 2
alcohol consumption rates are in the WHO European region and the WHO region of the Americas. In the United States, the 2011 National Survey on Drug Use and Health revealed that 6.2% of the US population aged 12 and over reported to be heavy users of alcohol (more than five drinks per day 3
during five or more days in the last month). Worldwide, 16% of alcohol drinkers engage in heavy episodic drinking, which is identified as having 60 grams of pure alcohol, or about six drinks in a single occasion, at least monthly.
2
Physiologically, during alcohol ingestion there is an inhibitory effect on the N-methyl-D-aspartate (NMDA) receptors and an agonistic effect on gamma-aminobutyric acid type-A (GABAA) receptors in
doi: 10.11124/jbisrir-2015-2529
Page 315
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
the central nervous system. This leads to tolerance in prolonged exposure to alcohol as the NMDA receptors are up-regulated while the GABAA receptors are down-regulated. In the absence of alcohol, these roles are reversed, leading to dopaminergic dysregulation and causing the signs and symptoms of alcohol withdrawal syndrome (AWS).
4
Alcohol withdrawal syndrome occurs when the alcohol dependent person suddenly decreases intake or completely stops drinking alcohol. It can begin as early as two to six hours after the last drink, or can have a delayed onset of 24-48 hours, and is characterized by tachycardia, diaphoresis, tremors, irritability, agitation, hypertension, seizures and sometimes delirium in the later stages.
4,5
Multiple
episodes of alcohol withdrawal lead to a “kindling” effect, whereby the intensity and severity of each withdrawal episode is increased.
6
Alcohol withdrawal delirium, or delirium tremens (DT), is marked by acute onset of disorientation and impaired cognition which develop over hours to days and usually follow a course of alcohol withdrawal. This course typically requires admission to the ICU, and involves sedation, intubation and mechanical ventilation. Pneumonia is a major comorbidity for patients who are admitted to the ICU with alcohol withdrawal delirium. Typically, delirium resolves in three to five days, but can last as long 4
as two weeks. The average length of stay in the ICU can be as long as 12.5 days. Patients who develop DT are at greater risk of dying during their hospitalization than those who do not progress past the mild and moderate stages of AWS.
7
Considering the widespread use of alcohol worldwide and the adverse effects of stopping habitual use of it, healthcare providers who care for these patients need to be well-trained in early identification, assessment, and management of AWS and DT. The 2014 JBI Evidence Summary describes the 8
following best practice recommendations when managing patients with AWS : 1. It is important to establish the risk of AWS, therefore a comprehensive alcohol history should be completed. 2. A baseline assessment of symptoms should be conducted using the CIWA-Ar scale. 3. If the patient's history is unobtainable, biochemical markers may be used to ascertain alcohol dependence. 4. Symptom-triggered therapy may be an effective treatment for AWS versus a fixed-dose approach. 5. The use of benzodiazepines with a gradual taper is recommended. 6. The administration of thiamine is recommended when treating patients with AWS as it can help prevent the Wernicke-Korsakoff syndrome. 7. Sedative hypnotic drugs are recommended over neuroleptics when treating alcohol withdrawal delirium. The setting in which this project was conducted was a medical surgical high acuity (MSHA) unit at a quaternary, 700-bed, academic medical center in the western United States. The MSHA unit is a fastpaced unit providing transitional level care with an acuity-driven average of 3:1 patient to nurse ratio. The unit has telemetry and continuous pulse oximetry capabilities for 28 beds. Complex patients on the unit include those with cardiovascular disorders, advanced lung diseases, multiple oncological
doi: 10.11124/jbisrir-2015-2529
Page 316
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
conditions, diabetic ketoacidosis, end stage liver disease, chronic kidney disease and end of life/palliative conditions. Over the past year the MSHA unit has also provided care for an increased number of patients with alcohol withdrawal. The current standard of care for patients admitted to the medical center with AWS includes two possible pathways. They are triaged by the providers in the Emergency Department (ED) according to the severity of their symptoms and are either admitted directly to the ICU (where CIWAAr monitoring can be ordered and implemented) or to the MSHA unit for close monitoring, where providers are restricted from ordering CIWA-Ar monitoring. Patients in the ICU are ordered one of the two alcohol withdrawal management order sets – “monitoring only”, which includes a frequency for CIW-Ar assessments and vitamins, or “monitoring and medications” which includes CIWA-Ar-based pharmacological interventions. At the time of the project, the MSHA nurses had not been trained in taking care of patients with AWS and using the CIWA-Ar scale as traditionally these patients were sent to the ICU. However, about seven to eight patients or more per month were being admitted to the MSHA, thereby creating a need for the nurses to be better prepared in anticipating their clinical needs. To ensure more consistent and evidence-based care, the JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) tools were used to increase compliance with best practice guidelines for properly assessing and managing patients undergoing AWS in the MSHA unit.
Aim and objectives The aim of this evidence implementation project was to promote evidence-based practice in the assessment and management of patients undergoing alcohol withdrawal syndrome in the MSHA unit. The following were the project objectives:
Determining the current compliance with evidence-based criteria regarding assessment and management of alcohol withdrawal syndrome in the MSHA unit.
Improving clinician overall knowledge regarding best practice in assessment and management of alcohol withdrawal syndrome.
Improving compliance with evidence-based criteria regarding assessment and management of patients with alcohol withdrawal syndrome.
Methods This evidence implementation project took place in the medical surgical high acuity unit (MSHA) at a large, academic medical center in the United States. This setting was chosen because no procedure existed for caring for patients with AWS who were being admitted with increased frequency. The sample included patients admitted to the MHSA unit with a primary or a secondary diagnosis of alcohol withdrawal. This evidence implementation project used PACES and GRiP audit and feedback tool. The PACES and GRiP framework for promoting evidence-based health care involved three phases of activity:
doi: 10.11124/jbisrir-2015-2529
Page 317
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
1. Establishing a multidisciplinary team for the project and undertaking a baseline audit based on criteria informed by the evidence. The audit was accomplished by retrospective review of the electronic health record (EHR) of patients admitted to MSHA unit whilst undergoing AWS. 2. Reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the GRiP framework. Strategies consisted of educating clinicians, piloting the ICU CIWA-Ar order set on MSHA, and creating a nursing procedure to assess and manage patients undergoing AWS on the MSHA unit. 3. Conducting the post-implementation audit and analyzing the results using a retrospective Ethical considerations This was a quality improvement project and, therefore, did not require ethics approval from the Institutional Review Board. Phase 1: Stakeholder engagement and baseline audit Stakeholders were identified and the established project team included clinicians from several disciplines. Hospital medicine, the usual admitting service for patients with alcohol withdrawal, was represented by the Medical Director who, as a subject matter expert for CIWA-Ar and AWS, was directly involved in this project. The Adult Acute Care Clinical Nurse Specialist (CNS) was integral as an advisor and expert in the adult and geriatric patient population. The Critical Care Nurse Practitioner, who originally implemented the alcohol withdrawal management order set in the ICU, served as an advisor and ICU liaison. The Nursing Department’s Evidence Implementation Nurse Specialist, an expert on institutional policy and procedures, advised and mentored the author throughout the project timeline. A baseline audit was conducted to assess current adherence to the evidence-based audit criteria. The sample was obtained by enlisting charge nurses to collect the names and medical record numbers of patients upon admission to MSHA with a primary or secondary diagnosis of alcohol withdrawal. This list was kept in the charge nurse binder at the nurses' station. The EHR was then audited for each of the five audit criteria. The Joanna Briggs Institute PACES program was used to collect the audit data (Table 1). A non-probabilistic, convenience sampling approach was used. A sample size of 15 was determined because it would be achievable given the project time frame in light of the estimated average number of alcohol withdrawal patients admitted monthly to the MSHA unit. The evidence informed audit criteria which were used in the project (baseline and follow up audit), together with a description of the sample and approach to measuring compliance with each audit criterion, are displayed in Table 1.
doi: 10.11124/jbisrir-2015-2529
Page 318
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Table 1: Audit criteria, sample and measurement criteria Audit criterion
Sample
Method
used
percentage
to
measure
compliance
with
best practice 1. Benzodiazepines are used Patients with alcohol withdrawal: A yes was allocated if to manage alcohol withdrawal symptoms
and
dosage
is
Baseline audit sample: 15 Follow-up audit sample: 15
gradually reduced.
benzodiazepines were ordered by the provider, administered by the nurse, and a gradual reduction in dosage was observed throughout the hospitalization.
2. Sedative hypnotic drugs are Patients with alcohol withdrawal A yes was allocated if sedative used as the primary agents for delirium:
hypnotic drugs were used as first-
managing alcohol withdrawal
line drugs, instead of neuroleptics
delirium.
Baseline audit sample: 15 Follow-up audit sample: 15
to treat alcohol withdrawal delirium; an NA was allocated if the patient did not develop alcohol withdrawal
delirium
while
hospitalized. 3. The severity of baseline Patients with alcohol withdrawal: A withdrawal
symptoms
is
assessed using the Clinical Institute
Baseline audit sample: 15
Withdrawal Follow-up audit sample: 15
Assessment Scale for Alcohol
yes
was
allocated
if
the
electronic health record (EHR) had
a
baseline
CIWA-Ar*
assessment documented within 24 hours of admission.
(CIWA-Ar).
*The current tool used at UCSF is called CIWA-Ar; however it had been
modified
tachycardia
into
to
include
the
graded
criteria. 4. There is a risk assessment Patients with alcohol withdrawal: A plan to identify patients at high risk of alcohol withdrawal.
Baseline audit sample: 15 Follow-up audit sample: 15
yes
was
allocated
if
the
provider's history and physical note addressed the patient's risk for alcohol withdrawal and a plan of care was in place.
5. Thiamine is administered as Patients with alcohol withdrawal: A yes was allocated if thiamine part of the management of people with alcohol withdrawal.
Baseline audit sample: 15
was ordered by the provider and administered by the nurse.
Follow-up audit sample: 15
doi: 10.11124/jbisrir-2015-2529
Page 319
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
The baseline audit began on September 1, 2014 and ended on November 30, 2014. The desired sample size was achieved. Phase 2: Design and implementation of strategies to improve practice (GRiP) The project team analyzed the baseline audit findings and developed implementation strategies to improve on the results.
Four out of five audit criteria resulted in greater than 90% compliance at baseline. A significant deficit in Criterion 3 – the severity of baseline symptoms is assessed using the CIWA-Ar scale – was recorded through a 53% compliance rate.
Guided by the GRiP framework, barriers to best practice were assessed in relation to the lack of baseline assessment with the CIWA-Ar scale. Strategies and resources to overcome this barrier were identified.
Strategies identified as feasible were implemented during the one-month period (January 2015). Table 2, the GRIP Matrix, presents the outcomes of the planned interventions.
Potential strategies to improve compliance with baseline CIWA-Ar scale were discussed with the stakeholders. It was evident the barriers to this practice were multifactorial: the standard of care for AWS in the MSHA unit did not require the nurses to assess the patients using the CIWA-Ar scale, there was no provider order set or procedure requiring them to do so, and a knowledge deficit existed relating to alcohol withdrawal and the use of CIWA-Ar scale. Pilot procedure development The plan to improve the compliance consisted of a two-pronged approach. In order to ensure that every patient who had a diagnosis of alcohol withdrawal had a baseline CIWA-Ar nursing assessment, a physician order or a formal procedure was required. Since the electronic health record (EHR) had the CIWA-Ar tool already built into the documentation flowsheets, nurses could readily start assessing the CIWA-Ar scale, per provider order, by adding the specific flowsheet to their patient screen. The barrier to using the available order sets was that they were originally developed for use only in the ICU. After further discussion with the CNS and the Medical Director, it was decided that the ICU “monitoring only” alcohol withdrawal management order set would be highly appropriate and feasible for use by transitional care nurses. This order set includes CIWA-Ar monitoring frequency, as well as oxygen administration, and a subset of vitamin orders (including thiamine). Therefore a pilot procedure was developed for the use in the ICU “monitoring only” order set in the MSHA unit. Educational intervention for nurses Once the procedure was developed by the author and reviewed by the CNS and the Medical Director, the next step was an educational intervention to prepare the nursing staff for the pilot. Although MSHA nurses frequently cared for patients with alcohol withdrawal, most lacked training in the management of alcohol withdrawal symptoms. To address this educational gap, the author created a slideshow presentation (please specify the duration of presentation) informed by the ICU alcohol withdrawal management educational module. It was presented at the January 2015 monthly staff meeting, which was attended by a third of the unit nurses (please specify the number of nurses). The
doi: 10.11124/jbisrir-2015-2529
Page 320
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
curricula included background information about alcohol withdrawal syndrome, phases of withdrawal, as well as a review of the CIWA-Ar scale. The teaching methodology also included an interactive case study where nurses worked together solving a challenging patient situation using the CIWA-Ar assessment to choose appropriate interventions. For the self-study methodology, nurses received a paper copy of the CIWA-Ar tool and a take-home quiz. Nurses who did not attend the staff meeting were emailed the slideshow presentation and the take-home quiz. To support to the educational intervention and pilot project, alcohol withdrawal management nurse super users (champions) were recruited by the author. These nurses were motivated by their interest in the subject, their comfort level in taking care of patients with alcohol withdrawal, or their familiarity with the CIWA-Ar or similar scales from previous job experiences. The super users received by email an additional slideshow with advanced education prior to the staff meeting presentation. They were also asked to serve as a resource for other nurses. Ten nurses agreed to be “CIWA super users”. Intervention for providers The providers also needed to be prepared for the pilot roll-out as they would be placing the appropriate orders when they admitted patients with alcohol withdrawal. A provider workflow diagram was developed to showcase the new versus previous workflow. A succinct presentation was created and incorporated into the larger orientation slideshow for the incoming interns and residents. The pilot was planned to begin on February 1 2015, chosen to coincide with the beginning of a new senior resident rotation. The interns received the presentation on January 22 2015 at their respective orientation. The short slideshow included the workflow diagram (Appendix I), as well as step-by-step instructions for ordering the specific order set used during the pilot. Long term goals and interventions During the initial research for this project, the author found that some aspects of the current ICU alcohol withdrawal management order set and the medical center’s version of the CIW A-Ar scale were not aligned with current best available evidence. Specifically, the CIWA-Ar had been modified to include tachycardia as a criterion, which is not in the standardized, validated tool. The order set also included certain drugs that were not frequently used, such as diazepam. Concurrent with this JBI evidence implementation project, a taskforce convened with the stakeholders, author and ICU and acute care pharmacists. The group aimed to: revise the current CIWA-Ar scale to remove tachycardia, update the ICU order set, and implement two new order sets. These order sets consisted of: 1) alcohol withdrawal observation order set to be used on the acute care or transitional care units, and 2) mild to moderate alcohol withdrawal order set to be used on the transitional care units. Another goal was for the adult acute care CNS and the author to develop a nursing department procedure to outline the steps in caring for patients with alcohol withdrawal. It would serve as a reference by nurses in all adult units of the hospital. Work is in progress to achieve these aims.
doi: 10.11124/jbisrir-2015-2529
Page 321
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Phase 3: Follow-up audit post implementation of change strategy The follow-up audit used the same evidence-based audit criteria as those used for the baseline audit. The sample consisted of 15 patients who were admitted to the MSHA unit with a primary or secondary diagnosis of alcohol withdrawal. The post-implementation audit took place from February 1 2015 to March 23 2015.
Results Phase 1: Baseline audit Baseline compliance with the evidence-based criteria was measured and entered into JBI-PACES. The desired sample of 15 patients was reached for each audit criteria. As can be seen in Figure 1, four out of five criteria showed 100% compliance with audit criteria.
Criteria legend: 1. Benzodiazepine are used to manage alcohol withdrawal symptoms and dosage is gradually reduced. 2. Sedative hypnotic drugs are used as the primary agents for managing alcohol withdrawal delirium. 3. The severity of baseline withdrawal symptoms is assessed using the Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar). 4. There is a risk assessment plan to identify patients at high risk of alcohol withdrawal. 5. Thiamine is administered as part of the management of people with alcohol withdrawal.
N = 15 for all criteria Figure 1: Compliance with best practice audit criteria in baseline audit (%) Baseline audit results for Criterion 1 revealed 100% compliance with the use of benzodiazepines to manage alcohol withdrawal symptoms, including a gradual taper. Lorazepam (Ativan) or chlordiazepoxide (Librium) are usually the first-line drugs ordered for patients with a history of habitual alcohol use and apparent symptoms of withdrawal. It was evident from the EHR that the dosage was decreased over the course of the hospitalization, either per a specific order for a “Librium taper” or in the case of symptom-triggered therapy, i.e. as the symptoms subsided the dosage and frequency gradually decreased. Criterion 2 involved the use of sedative hypnotic drugs in patients with alcohol withdrawal delirium. Eleven out of the 15 patients audited did not develop alcohol withdrawal delirium and were therefore marked as not applicable (NA). However, for the four patients who did have some degree of delirium, compliance was 100%. They required both increased doses of sedative hypnotics and neuroleptics. The sedative hypnotics were always used as the first-line drug, with the neuroleptics used as back-up for refractory hallucinations or psychosis. Results for Criterion 3 concerning CIWA-Ar assessments showed a sub-optimal compliance rate of only 53%. Eight out of the 15 patients sampled had a baseline CIWA-Ar assessment documented in
doi: 10.11124/jbisrir-2015-2529
Page 322
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
the EHR. These patients were either transferred from the ICU or the ED nurse had performed a CIWA-Ar assessment (although this is not common). The seven patients who were admitted directly to the MSHA unit from the ED did not have a baseline CIWA-Ar assessment documented in the EHR because the MSHA nurses did not routinely assess them using the CIWA-Ar tool. Criterion 4 measured the presence of an alcohol withdrawal risk assessment plan documented in the EHR. The physician admission note was audited for this information. All 15 patients sampled were admitted with a primary or secondary diagnosis of alcohol withdrawal. Every admission history and physical note mentioned “ETOH” or “ETOH withdrawal” on the problem list and was followed by a plan of care, such as, “admit to ICU for CIWA monitoring” for patients with a high initial CIWA-Ar score (usually assessed by the provider), or “admit to MSHA for observation and administer Ativan for withdrawal symptoms”. This audit criterion achieved 100% compliance. Criterion 5 examined whether thiamine was administered to patients with alcohol withdrawal. Thiamine is administered to patients with alcohol withdrawal to prevent Wernicke-Korsakoff 8
syndrome. There was 100% compliance with this evidence-based recommendation. The thiamine was ordered as soon as the patients were identified as being at risk of alcohol withdrawal and was administered by the nurses in all cases. Phase 2: Strategies for GRIP The lowest scoring criterion on the baseline audit revolved around the assessment using the CIWA-Ar scale. The most significant barrier to this practice was not the lack of availability of the scale – as previously mentioned it can be easily added into the electronic documentation flowsheets screen by any nurse. The problems were that a procedure did not exist for using the CIWA-Ar scale to assess the AWS patients and there was no provider order set MSHA nurses were required to use. Another barrier was the staff nurse educational gap which was reflected in their apprehensions about taking care of these patients and using the CIWA-Ar scale. Strategies are shown in the GRIP matrix (Table 2). To address the main barrier, several strategies were initiated. The author concluded that a simple unilateral approach of asking the nurses to use the CIWA-Ar scale to assess their patients with alcohol withdrawal would not yield a 100% compliance rate. Therefore a pilot procedure (Appendix II) was developed to use the alcohol withdrawal management “monitoring only” ICU order set on the MSHA unit. This procedure was reviewed and approved by the Adult Acute Care CNS, the Medical Director, and unit leadership. The procedure was made available for the nursing staff electronically as well as a hard copy on the unit in an “Alcohol Withdrawal Resources” binder. Prior to beginning the pilot procedure and using the CIWA-Ar scale, comprehensive nursing staff education had to address not just using the CIWA-Ar tool, but also the overall picture of the patient with alcohol withdrawal syndrome. The 2009 ICU alcohol withdrawal nurse training module informed the development of an educational slideshow geared towards the MSHA nurses’ needs and the future pilot. With the onset of the pilot, a digital resource folder was created on the hospital's network drive (accessible to all nurses on campus), and a physical folder (“Alcohol Withdrawal Resources”) for quick reference was placed at the nurses station. Both mirrored each other and included the educational slideshow, pilot procedure, relevant literature and workflow diagrams. Several emails were also sent
doi: 10.11124/jbisrir-2015-2529
Page 323
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
out to the entire staff throughout the pilot phase to address any issues that arose and to highlight key points. One significant point which had to be reiterated to both nursing staff and providers was that the CIWA-Ar scale available at the hospital had been modified to factor in and give weight to tachycardia, which is not included in the standardized CIWA-Ar tool. Nurses’ comprehension of this point was essential in case the CIWA-Ar score was artificially inflated due to tachycardia, which can be caused by many factors other than alcohol withdrawal. Providers were also informed of the tachycardia issue as this may have been different from their experiences using CIWA-Ar at other health care facilities. It was anticipated they would likely not be cognizant as they did not usually use the tool themselves but rather relied on the nurses’ documentation of the final score. The providers were also informed of the pilot during their orientation by the chief residents. The new workflow was explained through step-by-step instructions. Table 2: GRiP matrix Barrier
Resources
Outcomes
procedure
The adult acute care
– The
withdrawal
to pilot the ICU
CNS, the author’s JBI
management
only
coach, and the Medical
procedure and order
withdrawal
set for MSHA unit.
“monitoring
Lack
Strategy
of
alcohol
Create
alcohol
Director provided advice only”
order set.
and
reviewed
approved
the
and pilot
procedure. Lack
of
nurse
– Educate nursing
knowledge in AWS
staff
management
multi-modal
monthly staff meeting,
approach.
and emailed to absent
and
using CIWA-Ar scale.
using
– Provide
a
– A 30-minute slideshow
easily
accessible
staff. Content included didactic,
case
scenarios and tests.
resources. – Provide
was presented at the
“CIWA Updates” were nurse
periodically emailed to
super users as a
staff to highlight key
support.
points
and
address
pilot
began
on
February 1 2015. – 15 patients were admitted to the MSHA unit with alcohol withdrawal; each had an order for CIWA-Ar monitoring. – Nurses were engaged during the staff meeting as well as afterwards, asking questions and providing feedback in person and via email. – There was 100% compliance with documentation of CIWA-Ar score. – Zero patients transferred to ICU for alcohol withdrawal related reasons.
issues as they arose. – A digital and physical resource folder was created
and
made
available to all staff.
doi: 10.11124/jbisrir-2015-2529
Page 324
JBI Database of Systematic Reviews & Implementation Reports
Lack
of
education
in
management
nurse
Educate
AWS
nursing staff and
and
using CIWA-Ar scale.
provide
the easily
accessible
2015;13(12):314-334
– A 30-minute staff
Nurses
meeting slideshow was presented, and emailed to absent staff.
resources.
–
“CIWA
were
engaged
during the staff meeting as well as afterwards, asking
questions
providing
feedback
and in
updates”
person and via email. As
emails were also sent
a result there was a 100%
out to staff to inform
compliance
them about key points
documentation of CIWA-
and address any issues
Ar score.
with
as they arose. – A digital and physical resource
folder
created
for
was quick
reference and available to all staff. Change in provider
– Present
new
– A short slideshow and
All patients admitted to
workflow coupled with
workflow
to
workflow
diagram
MSHA unit with alcohol
frequently
providers
at
were used to inform
withdrawal as primary or
providers of the pilot.
secondary diagnosis were
rotating
house staff.
orientation. – Encourage feedback
– Chief residents aided and
in the dissemination of
interdisciplinary
this information during
communication.
monthly orientations.
required
to
undergo
CIWA-Ar monitoring.
Phase 3: Follow-up audit Results of the follow-up audit compared to the results of the baseline audits are shown in Figure 2. The desired sample size of 15 patients was reached for all criteria. The post-implementation findings were consistent with the baseline compliance rates, except for Criterion 3, which was the least compliant in the baseline audit (53%) and, therefore, the focus of improvement. Fifteen patients were sampled for Criterion 1 which was in relation to pharmacological management of AWS. One patient was marked as “NA” because the CIWA-Ar score was very low and the patient did not require any benzodiazepines. However, the other 14 patients had significant enough symptoms to warrant administration of benzodiazepines and they were gradually tapered, therefore compliance was 100% for the patients who did require a pharmacological intervention. Criterion 2 addressed patients who developed alcohol withdrawal delirium. Only one patient developed alcohol withdrawal delirium in the follow-up phase, and he was treated with sedative hypnotics as a first-line drug and neuroleptics as a back-up. Therefore, the compliance rate was 100% for this criterion. The other 14 patients did not develop delirium and were excluded from measurement.
doi: 10.11124/jbisrir-2015-2529
Page 325
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Criterion 3 achieved the greatest improvement compared to the baseline finding of 53% compliance. This criterion addressed whether a baseline assessment of alcohol withdrawal symptoms was completed using the CIWA-Ar scale. Results demonstrated an improvement of 47% over the baseline audit, thus 100% compliance with the criterion was reached. It means all patients admitted to the MSHA unit with alcohol withdrawal were assessed using the hospital’s version of the evidence-based CIWA-Ar scale. The result for Criterion 4 was consistent with that in the baseline audit of 100% compliance. The providers continued to address the alcohol use and potential for withdrawal in the admission note and subsequent progress notes. Criterion 5 assessed thiamine administration to patients with alcohol withdrawal. Of the 15 patients sampled, 14 were required to receive and who did receive thiamine during the course of their hospitalization. One patient was admitted for only one day and, although thiamine was ordered, the dose was documented as “refused” and, therefore, was allocated a “No” on the audit. This caused a 7% decrease in compliance but is not considered significant.
Criteria legend: 1. Benzodiazepine are used to manage alcohol withdrawal symptoms and dosage is gradually reduced. 2. Sedative hypnotic drugs are used as the primary agents for managing alcohol withdrawal delirium. 3. The severity of baseline withdrawal symptoms is assessed using the Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar). 4. There is a risk assessment plan to identify patients at high risk of alcohol withdrawal. 5. Thiamine is administered as part of the management of people with alcohol withdrawal.
N = 15 for all criteria in baseline and follow-up audits Figure 2: Compliance with the best practice audit criteria in follow up audit compared to baseline audit (%)
doi: 10.11124/jbisrir-2015-2529
Page 326
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Discussion This evidence implementation project focused on several aspects of improving the management of patients with alcohol withdrawal in a high acuity medical surgical transitional care unit. Using a multimodal approach, three important objectives were addressed: 1) assessing baseline compliance with JBI best practice recommendations, 2) improving clinician knowledge on managing patients with alcohol withdrawal, and 3) increasing compliance with best practice recommendations. All the objectives were successfully met and the least compliant criterion was significantly improved through strategic planning and interventions established during the course of this project. The major achievement was the MSHA nurses’ compliance with using the evidence-based CIWA-Ar tool and documenting the scores. The rate increased from 53% in the baseline audit to 100% in the follow-up audit. This could not have been achieved without interdisciplinary collaboration and collegial support of the stakeholders, nursing staff and physician colleagues. As a testament to the perceived value of the pilot, MSHA alcohol withdrawal patients continue to be assessed not only for some of the symptoms associated with alcohol withdrawal but for all of them. Most of the strategies implemented during the course of this project were successful in helping in the attainment of the goal of improving compliance with the evidence-based audit criteria. One strategy which was not as effective as desired was the use of nurse “CIWA super users”. Although 10 nurses agreed to be super users, it was clear the author could have provided more support during the pilot, and communicated their resource role to staff more frequently. In retrospect, holding a special super user classto ensure they received and understood the education and to better define their roles would have been useful. Despite the lackluster result of the super user intervention, the other interventions were successful. The nurses expressed very positive feedback on the staff meeting presentation and, ultimately, most attained a higher comfort level when caring for patients with alcohol withdrawal and using the CIWAAr scale. Their adoption of the tool signified they understood that this was the best and safest practice for the patients. Use of the CIWA-Ar scale has also aided communication during transitions of care as well as nurse communication with providers because the CIWA-Ar tool provides the same frame of reference for all clinicians involved in patient care. Continuity of care was certainly enhanced. The unexpected secondary outcome was none of the patients needed to be transferred to a higher level of care for withdrawal related reasons. Some challenges arose at the start of the pilot. Nursing staff expressed a level of anxiety regarding the initiation of CIWA-Ar monitoring in the MSHA unit since, historically, this was only done in the ICU. Through education and ongoing support from the author and the acute care CNS, much of these concerns were alleviated. Most nurses became readily comfortable with using the CIWA-Ar tool and adopted it into their practice as it had a valuable impact on their clinical judgment, patient care and workflow. Nurses expressed how they could see secondary, nurse-sensitive benefits, such as decreased falls and injuries. Creating an intervention which affects provider workflow in an academic medical center can be challenging. House staff constantly change services and locations. However, the providers were highly motivated and committed to making this pilot practice a success. Their commitment to caring for these patients based on the best evidence and achieving optimum
doi: 10.11124/jbisrir-2015-2529
Page 327
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
outcomes was demonstrated by the four provider-centered audit criteria scores of greater than 90% compliance at baseline and post-implementation. One significant limitation of this project was patient selection. Patients chosen for the audit had a primary or secondary diagnosis of alcohol withdrawal and were easier to identify. However, there were MSHA patients admitted to the unit for other reasons, for example, surgical patients and they may have been at risk for alcohol withdrawal. These patients could have benefitted from CIWA-Ar monitoring during the pilot. This dilemma raised a future nursing initiative for a more in-depth screening section on the nursing admission assessment tool to help identify at-risk patients. This project spawned several new initiatives at the unit level, as well as hospital-wide. An interdisciplinary taskforce was formed and has started revising the current ICU alcohol withdrawal order sets incorporating best available evidence. Additionally, the group will develop an order set to use in transitional care and acute care units. The overall aims are to increase clinician knowledge and awareness of alcohol withdrawal, increase safety, and potentially impact on patient satisfaction by increasing comfort levels and decreasing unnecessary transfers. The pilot initiated during this project will continue on the MSHA unit until a new order set and procedure are available.
Conclusion Increased admissions of patients with alcohol withdrawal to the MSHA unit have brought to light the need for a clear standard of care. The outcomes of this project have successfully demonstrated that alcohol withdrawal management can safely occur outside the ICU when the patients are appropriately triaged and treated according to symptom severity assessed with a standardized tool. Continuity of care was substantially impacted through not only enhanced nurse and provider knowledge of AWS but also interdisciplinary engagement in all phases and processes of the project. Use of CIWA-Ar is the MSHA unit is being sustained. Commitment to the project has resulted in plans for further areas of work concerning alcohol withdrawal management including adoption by other acute and transitional care units. A nursing procedure and provider order sets are being developed. On the continuum of care, discharge order sets for alcohol cessation referrals and pharmacotherapy are being planned.
Conflict of Interest There were no conflicts of interest to disclose.
Acknowledgements The author would like to acknowledge the assistance and support of: The Joanna Briggs Institute Evidence Based Clinical Fellowship Program Daphne Stannard, RN, PhD, CNS, FCCM,; Director and Chief Nurse Researcher, University of California San Francisco Medical Center, Institute for Nursing Excellence (INEx); Director, UCSF Center for Evidence-Based Patient and Family Care Melissa Lee, RN, MS, CNS-BC, Clinical Nurse Specialist Adult Medical-Surgical, University of California San Francisco Medical Center, Institute for Nursing Excellence (INEx)
doi: 10.11124/jbisrir-2015-2529
Page 328
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Pamela Worobel-Luk, RN, MSN, Evidence Implementation Nurse Specialist, University of California San Francisco Medical Center, Institute for Nursing Excellence (INEx); Convenor, UCSF Center for Evidence-Based Patient and Family Care
doi: 10.11124/jbisrir-2015-2529
Page 329
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
References 1. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009;373(9682):2223-2233. 2. Global status report on alcohol and health. World Health Organization; 2014. [Internet]. [Cited April 20, 2015]. Available from: http://apps.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf?ua=1 3. Results from the 2011 national survey on drug use and health: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. 168 p. Publication No. 12-4713. 4. McKeon, A, Frye MA, Delanty N. The alcohol withdrawal syndrome. J Neurol Neurosurg Psychiatry 2008;79(8):854-862. 5. Carlson RW, Kumar NN, Wong-McKinstry E, Ayyagari S, Puri N, Jackson FK, et al. Alcohol withdrawal syndrome. Crit Care Clin 2012; 28(4):549-585. 6. Ballenger JC, Post RM. Kindling as a model for alcohol withdrawal syndromes. Br J Psychiatry 1978; 133:1-14. 7. Monte R, Rbunal R, Casariego E, Lopez-Agreda H, Mateos A, Pertega S. Analysis of the factors determining survivial of alcoholic withdrawal syndrome patients in a general hospital. Alcohol Alcohol 2010;45(2)151-158. 8. Bataglini E. Alcohol withdrawal syndrome: management [Evidence Summary on the Internet]. The Joanna Briggs Institute; [Updated 2014 Sept 26; cited April 20, 2015]. Available from: http://connect.jbiconnectplus.org/ViewDocument.aspx?0=11634
doi: 10.11124/jbisrir-2015-2529
Page 330
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Appendix I: Current alcohol withdrawal workflow versus new workflow
doi: 10.11124/jbisrir-2015-2529
Page 331
JBI Database of Systematic Reviews & Implementation Reports
doi: 10.11124/jbisrir-2015-2529
2015;13(12):314-334
Page 332
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Appendix II: Pilot alcohol withdrawal management procedure
(Reproduced with permission from the UCSF Medical Center)
doi: 10.11124/jbisrir-2015-2529
Page 333
JBI Database of Systematic Reviews & Implementation Reports
doi: 10.11124/jbisrir-2015-2529
2015;13(12):314-334
Page 334
2015;13(12):314-334
Alcohol withdrawal management in adult patients in a high acuity medical surgical transitional care unit: a best practice implementation project
Olga Sukhenko
1,2
1. University of California San Francisco Medical Center, San Francisco, USA 2. UCSF Center for Evidence-Based Patient and Family Care: an Affiliate Center of the Joanna Briggs Institute; University of California San Francisco Medical Center
Primary contact Olga Sukhenko [email protected]
Key dates Commencement date: September, 2014 Completion date: March, 2015
Executive summary Background Excessive alcohol consumption, a major health problem worldwide, affects about 6% of the United States population. Caring for patients with alcohol withdrawal syndrome (AWS) in a hospital ward presents complex physiologic and psycho-social challenges which are best met with evidence-based practices. An academic medical center in the United States has been experiencing an increase in patients with AWS. However, gaps in clinician knowledge and infrastructure supporting the management of these patients still existed. Objectives The aim of this project was to improve the continuity of care of patients undergoing alcohol withdrawal in a medical surgical high acuity transitional care unit by incorporating evidencebased practices, and thereby to positively impact on patient outcomes. Specific objectives were related to standardized assessments and pharmacologic management strategies.
doi: 10.11124/jbisrir-2015-2529
Page 314
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Methods The project used the Joanna Briggs Institute’s Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit tool for promoting change in health practice. A baseline clinical audit was conducted to assess compliance with best practices for managing AWS, which was followed by several interventions targeted at nurses and providers. A follow-up audit was conducted to assess compliance with the implemented strategies. The follow-up audit used the same evidence-based audit criteria as those used for the baseline audit. A non-probabilistic, convenience sampling approach was used. A sample size of 15 patients was used for both the baseline and follow-up audits. Results The baseline audit revealed a high compliance rate for four of the five audit criteria concerning risk assessment and pharmacologic strategies. There was sub-optimal compliance (53%) with the criterion regarding use of the Clinical Institute Withdrawal Assessment of Alcohol Scale (revised) (CIWA-Ar) scale to assess patients with alcohol withdrawal. After the interventions were implemented this criterion recorded an improvement to 100% compliance. None of the patients in the pilot were transferred to the intensive care unit (ICU) for reasons relating to alcohol withdrawal. Conclusions The outcomes of this project demonstrated alcohol withdrawal management can be safely undertaken outside the ICU when the patients are appropriately assessed and treated for the severity of their withdrawal symptoms. This new clinical program significantly impacted on continuity of care. Challenges were resolved using an interdisciplinary team approach. The project resulted in plans for further areas of work concerning alcohol withdrawal management, including adoption of similar approaches by other acute and transitional care units. Keywords acute care; alcohol abuse; alcohol symptoms; alcohol withdrawal; screening
Background Alcohol abuse has detrimental effects and the clinical care of patients undergoing alcohol withdrawal 1
is highly complex because it combines physical factors with psycho-social issues. According to the World Health Organization (WHO) Global Status Report on Alcohol and Health 2014, the highest 2
alcohol consumption rates are in the WHO European region and the WHO region of the Americas. In the United States, the 2011 National Survey on Drug Use and Health revealed that 6.2% of the US population aged 12 and over reported to be heavy users of alcohol (more than five drinks per day 3
during five or more days in the last month). Worldwide, 16% of alcohol drinkers engage in heavy episodic drinking, which is identified as having 60 grams of pure alcohol, or about six drinks in a single occasion, at least monthly.
2
Physiologically, during alcohol ingestion there is an inhibitory effect on the N-methyl-D-aspartate (NMDA) receptors and an agonistic effect on gamma-aminobutyric acid type-A (GABAA) receptors in
doi: 10.11124/jbisrir-2015-2529
Page 315
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
the central nervous system. This leads to tolerance in prolonged exposure to alcohol as the NMDA receptors are up-regulated while the GABAA receptors are down-regulated. In the absence of alcohol, these roles are reversed, leading to dopaminergic dysregulation and causing the signs and symptoms of alcohol withdrawal syndrome (AWS).
4
Alcohol withdrawal syndrome occurs when the alcohol dependent person suddenly decreases intake or completely stops drinking alcohol. It can begin as early as two to six hours after the last drink, or can have a delayed onset of 24-48 hours, and is characterized by tachycardia, diaphoresis, tremors, irritability, agitation, hypertension, seizures and sometimes delirium in the later stages.
4,5
Multiple
episodes of alcohol withdrawal lead to a “kindling” effect, whereby the intensity and severity of each withdrawal episode is increased.
6
Alcohol withdrawal delirium, or delirium tremens (DT), is marked by acute onset of disorientation and impaired cognition which develop over hours to days and usually follow a course of alcohol withdrawal. This course typically requires admission to the ICU, and involves sedation, intubation and mechanical ventilation. Pneumonia is a major comorbidity for patients who are admitted to the ICU with alcohol withdrawal delirium. Typically, delirium resolves in three to five days, but can last as long 4
as two weeks. The average length of stay in the ICU can be as long as 12.5 days. Patients who develop DT are at greater risk of dying during their hospitalization than those who do not progress past the mild and moderate stages of AWS.
7
Considering the widespread use of alcohol worldwide and the adverse effects of stopping habitual use of it, healthcare providers who care for these patients need to be well-trained in early identification, assessment, and management of AWS and DT. The 2014 JBI Evidence Summary describes the 8
following best practice recommendations when managing patients with AWS : 1. It is important to establish the risk of AWS, therefore a comprehensive alcohol history should be completed. 2. A baseline assessment of symptoms should be conducted using the CIWA-Ar scale. 3. If the patient's history is unobtainable, biochemical markers may be used to ascertain alcohol dependence. 4. Symptom-triggered therapy may be an effective treatment for AWS versus a fixed-dose approach. 5. The use of benzodiazepines with a gradual taper is recommended. 6. The administration of thiamine is recommended when treating patients with AWS as it can help prevent the Wernicke-Korsakoff syndrome. 7. Sedative hypnotic drugs are recommended over neuroleptics when treating alcohol withdrawal delirium. The setting in which this project was conducted was a medical surgical high acuity (MSHA) unit at a quaternary, 700-bed, academic medical center in the western United States. The MSHA unit is a fastpaced unit providing transitional level care with an acuity-driven average of 3:1 patient to nurse ratio. The unit has telemetry and continuous pulse oximetry capabilities for 28 beds. Complex patients on the unit include those with cardiovascular disorders, advanced lung diseases, multiple oncological
doi: 10.11124/jbisrir-2015-2529
Page 316
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
conditions, diabetic ketoacidosis, end stage liver disease, chronic kidney disease and end of life/palliative conditions. Over the past year the MSHA unit has also provided care for an increased number of patients with alcohol withdrawal. The current standard of care for patients admitted to the medical center with AWS includes two possible pathways. They are triaged by the providers in the Emergency Department (ED) according to the severity of their symptoms and are either admitted directly to the ICU (where CIWAAr monitoring can be ordered and implemented) or to the MSHA unit for close monitoring, where providers are restricted from ordering CIWA-Ar monitoring. Patients in the ICU are ordered one of the two alcohol withdrawal management order sets – “monitoring only”, which includes a frequency for CIW-Ar assessments and vitamins, or “monitoring and medications” which includes CIWA-Ar-based pharmacological interventions. At the time of the project, the MSHA nurses had not been trained in taking care of patients with AWS and using the CIWA-Ar scale as traditionally these patients were sent to the ICU. However, about seven to eight patients or more per month were being admitted to the MSHA, thereby creating a need for the nurses to be better prepared in anticipating their clinical needs. To ensure more consistent and evidence-based care, the JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) tools were used to increase compliance with best practice guidelines for properly assessing and managing patients undergoing AWS in the MSHA unit.
Aim and objectives The aim of this evidence implementation project was to promote evidence-based practice in the assessment and management of patients undergoing alcohol withdrawal syndrome in the MSHA unit. The following were the project objectives:
Determining the current compliance with evidence-based criteria regarding assessment and management of alcohol withdrawal syndrome in the MSHA unit.
Improving clinician overall knowledge regarding best practice in assessment and management of alcohol withdrawal syndrome.
Improving compliance with evidence-based criteria regarding assessment and management of patients with alcohol withdrawal syndrome.
Methods This evidence implementation project took place in the medical surgical high acuity unit (MSHA) at a large, academic medical center in the United States. This setting was chosen because no procedure existed for caring for patients with AWS who were being admitted with increased frequency. The sample included patients admitted to the MHSA unit with a primary or a secondary diagnosis of alcohol withdrawal. This evidence implementation project used PACES and GRiP audit and feedback tool. The PACES and GRiP framework for promoting evidence-based health care involved three phases of activity:
doi: 10.11124/jbisrir-2015-2529
Page 317
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
1. Establishing a multidisciplinary team for the project and undertaking a baseline audit based on criteria informed by the evidence. The audit was accomplished by retrospective review of the electronic health record (EHR) of patients admitted to MSHA unit whilst undergoing AWS. 2. Reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the GRiP framework. Strategies consisted of educating clinicians, piloting the ICU CIWA-Ar order set on MSHA, and creating a nursing procedure to assess and manage patients undergoing AWS on the MSHA unit. 3. Conducting the post-implementation audit and analyzing the results using a retrospective Ethical considerations This was a quality improvement project and, therefore, did not require ethics approval from the Institutional Review Board. Phase 1: Stakeholder engagement and baseline audit Stakeholders were identified and the established project team included clinicians from several disciplines. Hospital medicine, the usual admitting service for patients with alcohol withdrawal, was represented by the Medical Director who, as a subject matter expert for CIWA-Ar and AWS, was directly involved in this project. The Adult Acute Care Clinical Nurse Specialist (CNS) was integral as an advisor and expert in the adult and geriatric patient population. The Critical Care Nurse Practitioner, who originally implemented the alcohol withdrawal management order set in the ICU, served as an advisor and ICU liaison. The Nursing Department’s Evidence Implementation Nurse Specialist, an expert on institutional policy and procedures, advised and mentored the author throughout the project timeline. A baseline audit was conducted to assess current adherence to the evidence-based audit criteria. The sample was obtained by enlisting charge nurses to collect the names and medical record numbers of patients upon admission to MSHA with a primary or secondary diagnosis of alcohol withdrawal. This list was kept in the charge nurse binder at the nurses' station. The EHR was then audited for each of the five audit criteria. The Joanna Briggs Institute PACES program was used to collect the audit data (Table 1). A non-probabilistic, convenience sampling approach was used. A sample size of 15 was determined because it would be achievable given the project time frame in light of the estimated average number of alcohol withdrawal patients admitted monthly to the MSHA unit. The evidence informed audit criteria which were used in the project (baseline and follow up audit), together with a description of the sample and approach to measuring compliance with each audit criterion, are displayed in Table 1.
doi: 10.11124/jbisrir-2015-2529
Page 318
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Table 1: Audit criteria, sample and measurement criteria Audit criterion
Sample
Method
used
percentage
to
measure
compliance
with
best practice 1. Benzodiazepines are used Patients with alcohol withdrawal: A yes was allocated if to manage alcohol withdrawal symptoms
and
dosage
is
Baseline audit sample: 15 Follow-up audit sample: 15
gradually reduced.
benzodiazepines were ordered by the provider, administered by the nurse, and a gradual reduction in dosage was observed throughout the hospitalization.
2. Sedative hypnotic drugs are Patients with alcohol withdrawal A yes was allocated if sedative used as the primary agents for delirium:
hypnotic drugs were used as first-
managing alcohol withdrawal
line drugs, instead of neuroleptics
delirium.
Baseline audit sample: 15 Follow-up audit sample: 15
to treat alcohol withdrawal delirium; an NA was allocated if the patient did not develop alcohol withdrawal
delirium
while
hospitalized. 3. The severity of baseline Patients with alcohol withdrawal: A withdrawal
symptoms
is
assessed using the Clinical Institute
Baseline audit sample: 15
Withdrawal Follow-up audit sample: 15
Assessment Scale for Alcohol
yes
was
allocated
if
the
electronic health record (EHR) had
a
baseline
CIWA-Ar*
assessment documented within 24 hours of admission.
(CIWA-Ar).
*The current tool used at UCSF is called CIWA-Ar; however it had been
modified
tachycardia
into
to
include
the
graded
criteria. 4. There is a risk assessment Patients with alcohol withdrawal: A plan to identify patients at high risk of alcohol withdrawal.
Baseline audit sample: 15 Follow-up audit sample: 15
yes
was
allocated
if
the
provider's history and physical note addressed the patient's risk for alcohol withdrawal and a plan of care was in place.
5. Thiamine is administered as Patients with alcohol withdrawal: A yes was allocated if thiamine part of the management of people with alcohol withdrawal.
Baseline audit sample: 15
was ordered by the provider and administered by the nurse.
Follow-up audit sample: 15
doi: 10.11124/jbisrir-2015-2529
Page 319
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
The baseline audit began on September 1, 2014 and ended on November 30, 2014. The desired sample size was achieved. Phase 2: Design and implementation of strategies to improve practice (GRiP) The project team analyzed the baseline audit findings and developed implementation strategies to improve on the results.
Four out of five audit criteria resulted in greater than 90% compliance at baseline. A significant deficit in Criterion 3 – the severity of baseline symptoms is assessed using the CIWA-Ar scale – was recorded through a 53% compliance rate.
Guided by the GRiP framework, barriers to best practice were assessed in relation to the lack of baseline assessment with the CIWA-Ar scale. Strategies and resources to overcome this barrier were identified.
Strategies identified as feasible were implemented during the one-month period (January 2015). Table 2, the GRIP Matrix, presents the outcomes of the planned interventions.
Potential strategies to improve compliance with baseline CIWA-Ar scale were discussed with the stakeholders. It was evident the barriers to this practice were multifactorial: the standard of care for AWS in the MSHA unit did not require the nurses to assess the patients using the CIWA-Ar scale, there was no provider order set or procedure requiring them to do so, and a knowledge deficit existed relating to alcohol withdrawal and the use of CIWA-Ar scale. Pilot procedure development The plan to improve the compliance consisted of a two-pronged approach. In order to ensure that every patient who had a diagnosis of alcohol withdrawal had a baseline CIWA-Ar nursing assessment, a physician order or a formal procedure was required. Since the electronic health record (EHR) had the CIWA-Ar tool already built into the documentation flowsheets, nurses could readily start assessing the CIWA-Ar scale, per provider order, by adding the specific flowsheet to their patient screen. The barrier to using the available order sets was that they were originally developed for use only in the ICU. After further discussion with the CNS and the Medical Director, it was decided that the ICU “monitoring only” alcohol withdrawal management order set would be highly appropriate and feasible for use by transitional care nurses. This order set includes CIWA-Ar monitoring frequency, as well as oxygen administration, and a subset of vitamin orders (including thiamine). Therefore a pilot procedure was developed for the use in the ICU “monitoring only” order set in the MSHA unit. Educational intervention for nurses Once the procedure was developed by the author and reviewed by the CNS and the Medical Director, the next step was an educational intervention to prepare the nursing staff for the pilot. Although MSHA nurses frequently cared for patients with alcohol withdrawal, most lacked training in the management of alcohol withdrawal symptoms. To address this educational gap, the author created a slideshow presentation (please specify the duration of presentation) informed by the ICU alcohol withdrawal management educational module. It was presented at the January 2015 monthly staff meeting, which was attended by a third of the unit nurses (please specify the number of nurses). The
doi: 10.11124/jbisrir-2015-2529
Page 320
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
curricula included background information about alcohol withdrawal syndrome, phases of withdrawal, as well as a review of the CIWA-Ar scale. The teaching methodology also included an interactive case study where nurses worked together solving a challenging patient situation using the CIWA-Ar assessment to choose appropriate interventions. For the self-study methodology, nurses received a paper copy of the CIWA-Ar tool and a take-home quiz. Nurses who did not attend the staff meeting were emailed the slideshow presentation and the take-home quiz. To support to the educational intervention and pilot project, alcohol withdrawal management nurse super users (champions) were recruited by the author. These nurses were motivated by their interest in the subject, their comfort level in taking care of patients with alcohol withdrawal, or their familiarity with the CIWA-Ar or similar scales from previous job experiences. The super users received by email an additional slideshow with advanced education prior to the staff meeting presentation. They were also asked to serve as a resource for other nurses. Ten nurses agreed to be “CIWA super users”. Intervention for providers The providers also needed to be prepared for the pilot roll-out as they would be placing the appropriate orders when they admitted patients with alcohol withdrawal. A provider workflow diagram was developed to showcase the new versus previous workflow. A succinct presentation was created and incorporated into the larger orientation slideshow for the incoming interns and residents. The pilot was planned to begin on February 1 2015, chosen to coincide with the beginning of a new senior resident rotation. The interns received the presentation on January 22 2015 at their respective orientation. The short slideshow included the workflow diagram (Appendix I), as well as step-by-step instructions for ordering the specific order set used during the pilot. Long term goals and interventions During the initial research for this project, the author found that some aspects of the current ICU alcohol withdrawal management order set and the medical center’s version of the CIW A-Ar scale were not aligned with current best available evidence. Specifically, the CIWA-Ar had been modified to include tachycardia as a criterion, which is not in the standardized, validated tool. The order set also included certain drugs that were not frequently used, such as diazepam. Concurrent with this JBI evidence implementation project, a taskforce convened with the stakeholders, author and ICU and acute care pharmacists. The group aimed to: revise the current CIWA-Ar scale to remove tachycardia, update the ICU order set, and implement two new order sets. These order sets consisted of: 1) alcohol withdrawal observation order set to be used on the acute care or transitional care units, and 2) mild to moderate alcohol withdrawal order set to be used on the transitional care units. Another goal was for the adult acute care CNS and the author to develop a nursing department procedure to outline the steps in caring for patients with alcohol withdrawal. It would serve as a reference by nurses in all adult units of the hospital. Work is in progress to achieve these aims.
doi: 10.11124/jbisrir-2015-2529
Page 321
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Phase 3: Follow-up audit post implementation of change strategy The follow-up audit used the same evidence-based audit criteria as those used for the baseline audit. The sample consisted of 15 patients who were admitted to the MSHA unit with a primary or secondary diagnosis of alcohol withdrawal. The post-implementation audit took place from February 1 2015 to March 23 2015.
Results Phase 1: Baseline audit Baseline compliance with the evidence-based criteria was measured and entered into JBI-PACES. The desired sample of 15 patients was reached for each audit criteria. As can be seen in Figure 1, four out of five criteria showed 100% compliance with audit criteria.
Criteria legend: 1. Benzodiazepine are used to manage alcohol withdrawal symptoms and dosage is gradually reduced. 2. Sedative hypnotic drugs are used as the primary agents for managing alcohol withdrawal delirium. 3. The severity of baseline withdrawal symptoms is assessed using the Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar). 4. There is a risk assessment plan to identify patients at high risk of alcohol withdrawal. 5. Thiamine is administered as part of the management of people with alcohol withdrawal.
N = 15 for all criteria Figure 1: Compliance with best practice audit criteria in baseline audit (%) Baseline audit results for Criterion 1 revealed 100% compliance with the use of benzodiazepines to manage alcohol withdrawal symptoms, including a gradual taper. Lorazepam (Ativan) or chlordiazepoxide (Librium) are usually the first-line drugs ordered for patients with a history of habitual alcohol use and apparent symptoms of withdrawal. It was evident from the EHR that the dosage was decreased over the course of the hospitalization, either per a specific order for a “Librium taper” or in the case of symptom-triggered therapy, i.e. as the symptoms subsided the dosage and frequency gradually decreased. Criterion 2 involved the use of sedative hypnotic drugs in patients with alcohol withdrawal delirium. Eleven out of the 15 patients audited did not develop alcohol withdrawal delirium and were therefore marked as not applicable (NA). However, for the four patients who did have some degree of delirium, compliance was 100%. They required both increased doses of sedative hypnotics and neuroleptics. The sedative hypnotics were always used as the first-line drug, with the neuroleptics used as back-up for refractory hallucinations or psychosis. Results for Criterion 3 concerning CIWA-Ar assessments showed a sub-optimal compliance rate of only 53%. Eight out of the 15 patients sampled had a baseline CIWA-Ar assessment documented in
doi: 10.11124/jbisrir-2015-2529
Page 322
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
the EHR. These patients were either transferred from the ICU or the ED nurse had performed a CIWA-Ar assessment (although this is not common). The seven patients who were admitted directly to the MSHA unit from the ED did not have a baseline CIWA-Ar assessment documented in the EHR because the MSHA nurses did not routinely assess them using the CIWA-Ar tool. Criterion 4 measured the presence of an alcohol withdrawal risk assessment plan documented in the EHR. The physician admission note was audited for this information. All 15 patients sampled were admitted with a primary or secondary diagnosis of alcohol withdrawal. Every admission history and physical note mentioned “ETOH” or “ETOH withdrawal” on the problem list and was followed by a plan of care, such as, “admit to ICU for CIWA monitoring” for patients with a high initial CIWA-Ar score (usually assessed by the provider), or “admit to MSHA for observation and administer Ativan for withdrawal symptoms”. This audit criterion achieved 100% compliance. Criterion 5 examined whether thiamine was administered to patients with alcohol withdrawal. Thiamine is administered to patients with alcohol withdrawal to prevent Wernicke-Korsakoff 8
syndrome. There was 100% compliance with this evidence-based recommendation. The thiamine was ordered as soon as the patients were identified as being at risk of alcohol withdrawal and was administered by the nurses in all cases. Phase 2: Strategies for GRIP The lowest scoring criterion on the baseline audit revolved around the assessment using the CIWA-Ar scale. The most significant barrier to this practice was not the lack of availability of the scale – as previously mentioned it can be easily added into the electronic documentation flowsheets screen by any nurse. The problems were that a procedure did not exist for using the CIWA-Ar scale to assess the AWS patients and there was no provider order set MSHA nurses were required to use. Another barrier was the staff nurse educational gap which was reflected in their apprehensions about taking care of these patients and using the CIWA-Ar scale. Strategies are shown in the GRIP matrix (Table 2). To address the main barrier, several strategies were initiated. The author concluded that a simple unilateral approach of asking the nurses to use the CIWA-Ar scale to assess their patients with alcohol withdrawal would not yield a 100% compliance rate. Therefore a pilot procedure (Appendix II) was developed to use the alcohol withdrawal management “monitoring only” ICU order set on the MSHA unit. This procedure was reviewed and approved by the Adult Acute Care CNS, the Medical Director, and unit leadership. The procedure was made available for the nursing staff electronically as well as a hard copy on the unit in an “Alcohol Withdrawal Resources” binder. Prior to beginning the pilot procedure and using the CIWA-Ar scale, comprehensive nursing staff education had to address not just using the CIWA-Ar tool, but also the overall picture of the patient with alcohol withdrawal syndrome. The 2009 ICU alcohol withdrawal nurse training module informed the development of an educational slideshow geared towards the MSHA nurses’ needs and the future pilot. With the onset of the pilot, a digital resource folder was created on the hospital's network drive (accessible to all nurses on campus), and a physical folder (“Alcohol Withdrawal Resources”) for quick reference was placed at the nurses station. Both mirrored each other and included the educational slideshow, pilot procedure, relevant literature and workflow diagrams. Several emails were also sent
doi: 10.11124/jbisrir-2015-2529
Page 323
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
out to the entire staff throughout the pilot phase to address any issues that arose and to highlight key points. One significant point which had to be reiterated to both nursing staff and providers was that the CIWA-Ar scale available at the hospital had been modified to factor in and give weight to tachycardia, which is not included in the standardized CIWA-Ar tool. Nurses’ comprehension of this point was essential in case the CIWA-Ar score was artificially inflated due to tachycardia, which can be caused by many factors other than alcohol withdrawal. Providers were also informed of the tachycardia issue as this may have been different from their experiences using CIWA-Ar at other health care facilities. It was anticipated they would likely not be cognizant as they did not usually use the tool themselves but rather relied on the nurses’ documentation of the final score. The providers were also informed of the pilot during their orientation by the chief residents. The new workflow was explained through step-by-step instructions. Table 2: GRiP matrix Barrier
Resources
Outcomes
procedure
The adult acute care
– The
withdrawal
to pilot the ICU
CNS, the author’s JBI
management
only
coach, and the Medical
procedure and order
withdrawal
set for MSHA unit.
“monitoring
Lack
Strategy
of
alcohol
Create
alcohol
Director provided advice only”
order set.
and
reviewed
approved
the
and pilot
procedure. Lack
of
nurse
– Educate nursing
knowledge in AWS
staff
management
multi-modal
monthly staff meeting,
approach.
and emailed to absent
and
using CIWA-Ar scale.
using
– Provide
a
– A 30-minute slideshow
easily
accessible
staff. Content included didactic,
case
scenarios and tests.
resources. – Provide
was presented at the
“CIWA Updates” were nurse
periodically emailed to
super users as a
staff to highlight key
support.
points
and
address
pilot
began
on
February 1 2015. – 15 patients were admitted to the MSHA unit with alcohol withdrawal; each had an order for CIWA-Ar monitoring. – Nurses were engaged during the staff meeting as well as afterwards, asking questions and providing feedback in person and via email. – There was 100% compliance with documentation of CIWA-Ar score. – Zero patients transferred to ICU for alcohol withdrawal related reasons.
issues as they arose. – A digital and physical resource folder was created
and
made
available to all staff.
doi: 10.11124/jbisrir-2015-2529
Page 324
JBI Database of Systematic Reviews & Implementation Reports
Lack
of
education
in
management
nurse
Educate
AWS
nursing staff and
and
using CIWA-Ar scale.
provide
the easily
accessible
2015;13(12):314-334
– A 30-minute staff
Nurses
meeting slideshow was presented, and emailed to absent staff.
resources.
–
“CIWA
were
engaged
during the staff meeting as well as afterwards, asking
questions
providing
feedback
and in
updates”
person and via email. As
emails were also sent
a result there was a 100%
out to staff to inform
compliance
them about key points
documentation of CIWA-
and address any issues
Ar score.
with
as they arose. – A digital and physical resource
folder
created
for
was quick
reference and available to all staff. Change in provider
– Present
new
– A short slideshow and
All patients admitted to
workflow coupled with
workflow
to
workflow
diagram
MSHA unit with alcohol
frequently
providers
at
were used to inform
withdrawal as primary or
providers of the pilot.
secondary diagnosis were
rotating
house staff.
orientation. – Encourage feedback
– Chief residents aided and
in the dissemination of
interdisciplinary
this information during
communication.
monthly orientations.
required
to
undergo
CIWA-Ar monitoring.
Phase 3: Follow-up audit Results of the follow-up audit compared to the results of the baseline audits are shown in Figure 2. The desired sample size of 15 patients was reached for all criteria. The post-implementation findings were consistent with the baseline compliance rates, except for Criterion 3, which was the least compliant in the baseline audit (53%) and, therefore, the focus of improvement. Fifteen patients were sampled for Criterion 1 which was in relation to pharmacological management of AWS. One patient was marked as “NA” because the CIWA-Ar score was very low and the patient did not require any benzodiazepines. However, the other 14 patients had significant enough symptoms to warrant administration of benzodiazepines and they were gradually tapered, therefore compliance was 100% for the patients who did require a pharmacological intervention. Criterion 2 addressed patients who developed alcohol withdrawal delirium. Only one patient developed alcohol withdrawal delirium in the follow-up phase, and he was treated with sedative hypnotics as a first-line drug and neuroleptics as a back-up. Therefore, the compliance rate was 100% for this criterion. The other 14 patients did not develop delirium and were excluded from measurement.
doi: 10.11124/jbisrir-2015-2529
Page 325
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Criterion 3 achieved the greatest improvement compared to the baseline finding of 53% compliance. This criterion addressed whether a baseline assessment of alcohol withdrawal symptoms was completed using the CIWA-Ar scale. Results demonstrated an improvement of 47% over the baseline audit, thus 100% compliance with the criterion was reached. It means all patients admitted to the MSHA unit with alcohol withdrawal were assessed using the hospital’s version of the evidence-based CIWA-Ar scale. The result for Criterion 4 was consistent with that in the baseline audit of 100% compliance. The providers continued to address the alcohol use and potential for withdrawal in the admission note and subsequent progress notes. Criterion 5 assessed thiamine administration to patients with alcohol withdrawal. Of the 15 patients sampled, 14 were required to receive and who did receive thiamine during the course of their hospitalization. One patient was admitted for only one day and, although thiamine was ordered, the dose was documented as “refused” and, therefore, was allocated a “No” on the audit. This caused a 7% decrease in compliance but is not considered significant.
Criteria legend: 1. Benzodiazepine are used to manage alcohol withdrawal symptoms and dosage is gradually reduced. 2. Sedative hypnotic drugs are used as the primary agents for managing alcohol withdrawal delirium. 3. The severity of baseline withdrawal symptoms is assessed using the Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar). 4. There is a risk assessment plan to identify patients at high risk of alcohol withdrawal. 5. Thiamine is administered as part of the management of people with alcohol withdrawal.
N = 15 for all criteria in baseline and follow-up audits Figure 2: Compliance with the best practice audit criteria in follow up audit compared to baseline audit (%)
doi: 10.11124/jbisrir-2015-2529
Page 326
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Discussion This evidence implementation project focused on several aspects of improving the management of patients with alcohol withdrawal in a high acuity medical surgical transitional care unit. Using a multimodal approach, three important objectives were addressed: 1) assessing baseline compliance with JBI best practice recommendations, 2) improving clinician knowledge on managing patients with alcohol withdrawal, and 3) increasing compliance with best practice recommendations. All the objectives were successfully met and the least compliant criterion was significantly improved through strategic planning and interventions established during the course of this project. The major achievement was the MSHA nurses’ compliance with using the evidence-based CIWA-Ar tool and documenting the scores. The rate increased from 53% in the baseline audit to 100% in the follow-up audit. This could not have been achieved without interdisciplinary collaboration and collegial support of the stakeholders, nursing staff and physician colleagues. As a testament to the perceived value of the pilot, MSHA alcohol withdrawal patients continue to be assessed not only for some of the symptoms associated with alcohol withdrawal but for all of them. Most of the strategies implemented during the course of this project were successful in helping in the attainment of the goal of improving compliance with the evidence-based audit criteria. One strategy which was not as effective as desired was the use of nurse “CIWA super users”. Although 10 nurses agreed to be super users, it was clear the author could have provided more support during the pilot, and communicated their resource role to staff more frequently. In retrospect, holding a special super user classto ensure they received and understood the education and to better define their roles would have been useful. Despite the lackluster result of the super user intervention, the other interventions were successful. The nurses expressed very positive feedback on the staff meeting presentation and, ultimately, most attained a higher comfort level when caring for patients with alcohol withdrawal and using the CIWAAr scale. Their adoption of the tool signified they understood that this was the best and safest practice for the patients. Use of the CIWA-Ar scale has also aided communication during transitions of care as well as nurse communication with providers because the CIWA-Ar tool provides the same frame of reference for all clinicians involved in patient care. Continuity of care was certainly enhanced. The unexpected secondary outcome was none of the patients needed to be transferred to a higher level of care for withdrawal related reasons. Some challenges arose at the start of the pilot. Nursing staff expressed a level of anxiety regarding the initiation of CIWA-Ar monitoring in the MSHA unit since, historically, this was only done in the ICU. Through education and ongoing support from the author and the acute care CNS, much of these concerns were alleviated. Most nurses became readily comfortable with using the CIWA-Ar tool and adopted it into their practice as it had a valuable impact on their clinical judgment, patient care and workflow. Nurses expressed how they could see secondary, nurse-sensitive benefits, such as decreased falls and injuries. Creating an intervention which affects provider workflow in an academic medical center can be challenging. House staff constantly change services and locations. However, the providers were highly motivated and committed to making this pilot practice a success. Their commitment to caring for these patients based on the best evidence and achieving optimum
doi: 10.11124/jbisrir-2015-2529
Page 327
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
outcomes was demonstrated by the four provider-centered audit criteria scores of greater than 90% compliance at baseline and post-implementation. One significant limitation of this project was patient selection. Patients chosen for the audit had a primary or secondary diagnosis of alcohol withdrawal and were easier to identify. However, there were MSHA patients admitted to the unit for other reasons, for example, surgical patients and they may have been at risk for alcohol withdrawal. These patients could have benefitted from CIWA-Ar monitoring during the pilot. This dilemma raised a future nursing initiative for a more in-depth screening section on the nursing admission assessment tool to help identify at-risk patients. This project spawned several new initiatives at the unit level, as well as hospital-wide. An interdisciplinary taskforce was formed and has started revising the current ICU alcohol withdrawal order sets incorporating best available evidence. Additionally, the group will develop an order set to use in transitional care and acute care units. The overall aims are to increase clinician knowledge and awareness of alcohol withdrawal, increase safety, and potentially impact on patient satisfaction by increasing comfort levels and decreasing unnecessary transfers. The pilot initiated during this project will continue on the MSHA unit until a new order set and procedure are available.
Conclusion Increased admissions of patients with alcohol withdrawal to the MSHA unit have brought to light the need for a clear standard of care. The outcomes of this project have successfully demonstrated that alcohol withdrawal management can safely occur outside the ICU when the patients are appropriately triaged and treated according to symptom severity assessed with a standardized tool. Continuity of care was substantially impacted through not only enhanced nurse and provider knowledge of AWS but also interdisciplinary engagement in all phases and processes of the project. Use of CIWA-Ar is the MSHA unit is being sustained. Commitment to the project has resulted in plans for further areas of work concerning alcohol withdrawal management including adoption by other acute and transitional care units. A nursing procedure and provider order sets are being developed. On the continuum of care, discharge order sets for alcohol cessation referrals and pharmacotherapy are being planned.
Conflict of Interest There were no conflicts of interest to disclose.
Acknowledgements The author would like to acknowledge the assistance and support of: The Joanna Briggs Institute Evidence Based Clinical Fellowship Program Daphne Stannard, RN, PhD, CNS, FCCM,; Director and Chief Nurse Researcher, University of California San Francisco Medical Center, Institute for Nursing Excellence (INEx); Director, UCSF Center for Evidence-Based Patient and Family Care Melissa Lee, RN, MS, CNS-BC, Clinical Nurse Specialist Adult Medical-Surgical, University of California San Francisco Medical Center, Institute for Nursing Excellence (INEx)
doi: 10.11124/jbisrir-2015-2529
Page 328
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Pamela Worobel-Luk, RN, MSN, Evidence Implementation Nurse Specialist, University of California San Francisco Medical Center, Institute for Nursing Excellence (INEx); Convenor, UCSF Center for Evidence-Based Patient and Family Care
doi: 10.11124/jbisrir-2015-2529
Page 329
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
References 1. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009;373(9682):2223-2233. 2. Global status report on alcohol and health. World Health Organization; 2014. [Internet]. [Cited April 20, 2015]. Available from: http://apps.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf?ua=1 3. Results from the 2011 national survey on drug use and health: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. 168 p. Publication No. 12-4713. 4. McKeon, A, Frye MA, Delanty N. The alcohol withdrawal syndrome. J Neurol Neurosurg Psychiatry 2008;79(8):854-862. 5. Carlson RW, Kumar NN, Wong-McKinstry E, Ayyagari S, Puri N, Jackson FK, et al. Alcohol withdrawal syndrome. Crit Care Clin 2012; 28(4):549-585. 6. Ballenger JC, Post RM. Kindling as a model for alcohol withdrawal syndromes. Br J Psychiatry 1978; 133:1-14. 7. Monte R, Rbunal R, Casariego E, Lopez-Agreda H, Mateos A, Pertega S. Analysis of the factors determining survivial of alcoholic withdrawal syndrome patients in a general hospital. Alcohol Alcohol 2010;45(2)151-158. 8. Bataglini E. Alcohol withdrawal syndrome: management [Evidence Summary on the Internet]. The Joanna Briggs Institute; [Updated 2014 Sept 26; cited April 20, 2015]. Available from: http://connect.jbiconnectplus.org/ViewDocument.aspx?0=11634
doi: 10.11124/jbisrir-2015-2529
Page 330
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Appendix I: Current alcohol withdrawal workflow versus new workflow
doi: 10.11124/jbisrir-2015-2529
Page 331
JBI Database of Systematic Reviews & Implementation Reports
doi: 10.11124/jbisrir-2015-2529
2015;13(12):314-334
Page 332
JBI Database of Systematic Reviews & Implementation Reports
2015;13(12):314-334
Appendix II: Pilot alcohol withdrawal management procedure
(Reproduced with permission from the UCSF Medical Center)
doi: 10.11124/jbisrir-2015-2529
Page 333
JBI Database of Systematic Reviews & Implementation Reports
doi: 10.11124/jbisrir-2015-2529
2015;13(12):314-334
Page 334
