ETOH withdrawal, CIWA, and transfer to the ICU.

[HeadingWest]

I work on a med-surg/tele floor that gets a fair number of ETOH withdrawal patients. Today I took care of a woman that had been sober 9 months before starting a 2 week bender prior to admission. She was up to a liter of vodka a day prior to going to the ED and even stopped for shots on the way in.

Her CIWA score was all over the place for night shift (probably because she was seen on camera taking her own PO ativan). I received her at 0645 (~18 hours since her last drink). I initially scored her at 17 and gave 4 mg IV ativan (per protocol). An hour later I scored her at 18 and gave her 30 mg of scheduled tranxene. The tranxene helped tremendously. She then scored an 8, received 2 mg of IV ativan, and scored a 9 post-medication. Next score was a 10 with another 2 mg of ativan given. Before the hour was up for a recheck she called the CNA and complained of hallucinations. At this point she was just past the 24 mark since her last drink.

I go in and she is crawling up the walls with anxiety (which she described as panic level), restless, nauseated, moderate headache, having trouble talking due to her tremors, hearing whispering voices, seeing spider webs, sweaty palms, tingling in her hands and feet, and saying she isn't going to make it through withdrawal. She remained oriented, but I scored at a 27. Her vials were stable the entire time (pressures in the low 100s, respers in the mid teens, heart rate in the 70s, afebrile).

I page her attending and he comes to see her. He agrees that she needs to be transferred to the ICU. By the time everything is taken care of for the transfer and I get her down to the ICU ~45 minutes have elapsed. She had calmed down and was no longer climbing up the walls as I was giving bedside report to her nurse, but the ICU charge commented "Apparently she is scoring in the 20s *eyes-rolling*".

I'm thinking to myself ***, hospital protocol is to transfer to ICU at 19, even with generous scoring she is high enough for the transfer. Why does it matter that she isn't disoriented or jumping out of bed?

I kept her on my pt list and checked their initial CIWA score after I got back up to my floor. They scored her a 4. I was expecting a lower score since she had calmed down, but 4? How is that even possible? If I'm ever in doubt about how I'm scoring someone I get another nurse to independently score and compare. I'm always within a few points of the other nurse.

I'm at a loss and wondering why there was such a discrepancy. Anyone have thoughts on the matter?

[poppycat, ADN, BSN]

My first thought is that you violated HIPAA by accessing her chart after she was transferred.

[HeadingWest]

Except that I still had to document her last bit of IV intake, my communication with the attending, and write a note regarding transfer/report which included reviewing her CIWA scores to ensure an accurate note.

Thanks for intentionally missing the point though.

[Whispera, MSN, RN]

Her score could be significantly lower if she had more medications on board, or if those she had already taken had finally totally kicked-in.

Also, sometimes people who aren't empathic to those in withdrawal, tend to score the CIWA lower due to their own prejudices.

[isis07734]

Good point whispera. Another thing to consider would be if they ended up needing to control her airway, that would drop the score :-P

We have 24 hrs to back chart I believe, in case we miss something, we are free to go into an old chart and catch up charting etc.

[PCnurse88]

CIWA scores are so unpredictabe because they are extremely subjective. Just yesterday I received report that a patient was off the walls and scoring a 15... I scored the patient a 3 all day, didn't need any extra ativan besides what was scheduled, and the patient slept all day. However, the night nurse had been giving both the scheduled and extra doses for her entire 12 hour shift. It could have just been all the ativan finally kicking in. I'm not familiar with tranxene, but it's possible you gave the patient all these meds that finally decided to work once she reached ICU.

Also remember, it is the ATTENDING who transferred this patient to the ICU. While most nurses know when a patient needs to go to the unit, we need a doctor to actually do it. You clearly weren't the only one thinking that this patient needed an ICU bed. I wouldn't worry about it. Our job is to keep the patients safe and (for our detoxers) stop them from seizing. Sounds like you did a great job.

[MunoRN, RN]

There can actually be very little difference between a score of 4 and a score of 27, which is why the total score isn't all that useful in itself, particularly for the purpose of determining what acuity level the patient is.

The standard CIWA looks at 10 different symptoms, and puts most of those symptoms on a 1-7 scale. A patient who is displaying 4 out of the 10 symptoms can have a score anywhere from 4 to 28, depending on the severity of the symptoms. A patient prior to being medicated might be 28, and then 4 just after being medicated. What's more useful is to take into account the number of symptoms the patient is presenting, and more importantly which particular symptoms are being presented. A patient who's only symptoms are some tremors, agitation, and not oriented to place might only have a 17 even with severe symptoms yet that patient is going to be extremely challenging in terms of nursing care. A patient who scores high on a number of symptoms, but is oriented and cooperative, might have a score well above 20, but is much easier to take care of.

[zacarias, ASN, RN]

Poppycat,

I see you have a lot of experience in nursing . As if you're scanning member posts to see where you can call the poster on their misdeeds. As stated, she was charting on the patient when she got back to her home unit so no real HIPAA violation here.

[adamRn79, BSN, RN]

You did everything right. The ICU wants to give them a low score so they can transfer the patient back to floor. The MD made the right decision to transfer, I'm impressed he/she actually evaluated the patient before sending them.