What's Your Alcohol Withdrawal Assessment Protocol?

  1. We are having some trouble with ours, which is CAGE. The problem is that the initial orders say to administer the assessment if the pt answers YES to one or more CAGE questions. If the pt scores 10 or higher, call the doc and initiate Ativan dosing. BUT someone has to nearly be in DT's before they reach a 10. In other words, the scale does not allow for Ativan dosing if someone is SYMPTOMATIC but scoring less than 10. However, the next paragraph says "give one mg of Ativan if PT scores 6 to 9". We all got in trouble for med errors for dosing at 6 even though it is right there in black and white! The reasoning is that a score of 6 "IMPLIES" that you call the doctor for a specific order to dose at 6. Otherwise no Ativan til they score 10. Yesterday we had a detoxer with BP of 190/156 and couldn't give Ativan because she scored 8! Someone is going to throw a stroke if we have to wait that long to dose.
    Isn't there a better protocol than CAGE? Admin says CAGE is national but I think they are pulling our collective leg.
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  2. 12 Comments

  3. by   Antikigirl
    We use a CIWA scale, and I haven't had too many problems the times I have had to use them. The ativan dosing is pretty liberal in my opinion, and if I feel the pt needs ativan even if it isn't scoring high enough...a call to the prescribing MD usually does the trick!

    I mean, if a pt isn't on a CIWA scale...they can get PRN Ativan dependant on s/sx right?!?! So I call the MD with my chart and MAR in hand, discribe the symptoms and recent meds, CIWA score, and my opinion. Typically I can get the ativan if I feel it is necessary, or the MD will evaluate.

    My mindset says...treat the patient, not a piece of paper or machine reading...so I tend to treat what I see and chart like crazy to compensate for the paper or machine ...
  4. by   cardiacRN2006
    We use CIWA also, and I agree that it is pretty liberal. If I have a pt on CIWA chances are I'm giving Ativan or Librium all the dang time.

    At the last hospital I worked at we didn't have any ETOH order sheets to work off of. If a pt was an alcoholic, we just gave them a beer or glass of wine for dinner. If they were really bad, then they would get 2 a day. It was a CVICU, so they didn't stay hositalized long. The actually alcohol worked like a charm. Never even saw tremors on pts.
  5. by   morte
    what WITHDRAWAL assessment tool are you using??
  6. by   Meerkat
    Quote from morte
    what WITHDRAWAL assessment tool are you using??
    As I said, we use CAGE:

    Do you feel that you should CUT back on your drinking?
    Have you been ANNOYED by people who comment on your drinking habit?
    Have you felt GUILTY about your drinking?
    Do you need a morning EYE opener?

    I think it is a STUPIDLY worded and poor assessment. Triage Nurse, yes we can call the doc for a PRN if they don't score ten, but we have to PAGE our docs and sometimes they take their sweet time getting back. I totally agree with you about treating the patient. I'm afraid if we don't getting better standing orders for withdrawal, that someone is going to die or stroke.
  7. by   santhony44
    I thought the purpose of the CAGE was to assess for a drinking problem, not imminent DT's. Is that even an appropriate use of the tool?

    I can see how, if someone has a drinking problem, the higher the number maybe the more likely they are to have DT's, but I don't think that's what the tool was designed for.
  8. by   Mama Val
    When I work at Detox we use the CIWA and it allows for a lot of wiggle room as needed. We use Librium unless the pt is allergic or not responding then we use the Ativan. The pts up here like the Ativan a little tooooooo much.
    We can give up to 600-700mg qDay of Librium with an ANPs order. We use it for the anxiety and HTN assoc with the withdrawl.
    When I work at the jail we used to have a P&P that just assesed the VS now we have this new guideline that we follow and we use Tranxene- I hate the stuff and there is no acomidation for those old tymers who Detox harder than the newer drunks. Its just done by paper not by patient so that leaves our hands a little tied unless we can get hold of somebody for an order. Its like they don't trust us to make assessments and decisions ...and thats another story all together.
    Last edit by Mama Val on Sep 5, '06
  9. by   elkpark
    The CAGE quiz is a screening test for whether or not people have problems with alcohol -- it has no connection to withdrawal symptoms. It's NOT a "withdrawal assessment protocol," and was never intended to be.

    The CIWA scale (with benzos) is the best system I've encountered over the years -- objective measures of w/d sxs (much more than just VS), but enough subjective "wiggle room" (as another poster noted) to make it practical/useful for a wide range of people.
  10. by   zolly786
    we use something very close to the ciwa assessment. the levels are a little different and it's based a lot on vitals as well. if you're over 10 or symptomatic, you can give it.

    we use valium or ativan depending on liver function.
    sometimes docs will order librium, depending on the pt.
  11. by   zolly786
    ok, lemme rephrase that.

    if THEY'RE over 10, you can give it.

    if YOU'RE over 10, i guess you can take it. sheesh. i need to learn to read.
  12. by   Meerkat
    Quote from elkpark
    The CAGE quiz is a screening test for whether or not people have problems with alcohol -- it has no connection to withdrawal symptoms. It's NOT a "withdrawal assessment protocol," and was never intended to be.

    The CIWA scale (with benzos) is the best system I've encountered over the years -- objective measures of w/d sxs (much more than just VS), but enough subjective "wiggle room" (as another poster noted) to make it practical/useful for a wide range of people.
    Yes but for us, an YES answer to CAGE initiates the Ativan protocol, which is based on scores. I guess I should have been more clear...the problem is the alcohol withdrawal assessment scale that acts as a Part II of CAGE per our policy.
  13. by   ICRN2008
    The hospital I did clinicals at this summer used the CIWA protocol on the med-surg unit. I had to perform the assessment a few times, and in my limited experience the score seemed to correlate well with the patent's level of withdrawal.

    As an aside, I was wondering what each of you would do if you found a patient drinking in his or her room. I encountered this situation twice this summer, and the nurses just waited for the patient to go for a walk and then searched the room and confiscated the alcohol (or cigarettes in another case). As a student nurse, I was told by my instructor that I did not have the authority to do anything except to report this behavior to the patient's RN.
  14. by   Antikigirl
    OH this reminds me...of my patient of last week! And a warning to us all!

    Okay..so an MD wanted this lady on a CIWA scale, but she didn't drink!!! A nurse before me told her the reason behind the questions...and I guess that is valid, but I actually do that as part of my assessment anyway...but anyhoo...oh man was she MAD!!!!!!!! I don't blame her!~

    So she is actually sueing now for breach of patient rights...which she does have..she didn't know three times that she was actually going on treatment from the assessment! She had the right to refuse! Sad..and really she was really a down to earth lady!

    Look at your hospital/facility protocols about this...do you let them know? Or do you just use this as part of assessment? (I treat pts by MD order on signs and symptoms..but...it is my discression!).

    SHe will soooooooooooo win her case! Not to mention they violated a HIPPA in the meantime!

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