How are you assessing alcohol withdrawal?

[nj3456]

The Unit Based Shared Governance committee at the hospital at which I'm working is looking to explore why we're having such high rates of patients going into severe DTs, requiring high-dose Ativan drips. Through a little research, I'm convinced it may be as simple as us not using CIWA protocols. There was an attempt to roll this out two years ago, but there wasn't any education on it, so it failed (as in, nurses were refusing to use it and sticking with our fixed dose/fixed schedule dosing).

What are you using at your hospital - fixed dose/schedule (for example, Q6 Librium around the clock with PRN Ativan), or CIWA? Are people becoming too over-sedated with CIWA? Feel free to add anything relevant - are your docs OK with Haldol as an adjunct? Phenobarbital?

For MICU nurses, are you using Precedex? Is your protocol that they need to be intubated for Precedex? Either way, do you feel that it works?

Thank you for your input! :)

[Been there,done that, ASN, RN]

CIWA is the most comprehensive method of assessing and treating alcohol withdrawal.

My job is to assess medical necessity required for payment. I use InterQual guidelines to make the medical necessity determination.

CIWA is the ONLY scoring tool InterQual recognizes.

In other words, if the facility wants payment, CIWA is the way to go.

[Meriwhen, ASN, BSN, MSN, RN]

CIWA with Ativan or Librium.

[Jules A, MSN]

The only issue I can think of from stopping psych meds is withdrawing from the meds themselves. However you can treat the symptoms with ativan, give them meds to help them sleep, and give them meds for diarrhea.[/quote']

I'm not sure if I understood you but with most antipsychotic meds the risk of abrupt discontinuation is not withdrawal symptoms as much as causing the patient to psychiatrically decompensate. A schizophrenic patient for example generally should not be taken off their medications if their isn't a medical indication.

[Karou]

We use CIWA. I do see patients occasionally under medicated either due to the nurse being afraid of over-sedation, or the nurse not being able to reassess in a timely manner. I think there needs to be more education on med surg RN's for using CIWA and managing alcohol withdrawal appropriately.

We only sent to PCU/ICU if they have a high score (forget specific #) twice consecutively.

[ixchel]

I'm not sure if I understood you but with most antipsychotic meds the risk of abrupt discontinuation is not withdrawal symptoms as much as causing the patient to psychiatrically decompensate. A schizophrenic patient for example generally should not be taken off their medications if their isn't a medical indication.

This is my understanding as well. At the least, we need a Psychiatrist to be handling which meds are safe to stop, and which are vital to remain. I've never seen psychiatrist on the list of job openings. Not even a PMHNP. Nothing. Lately I've been fired up enough about this that truly, I am considering running this up the chain. I know we are limited in some ways, being in a rural area, but I've had instances that feel borderline unsafe or inadequate by far, and that bothers me.

[pecas]

CIWA with Librium.

[Jules A, MSN]

This is my understanding as well. At the least, we need a Psychiatrist to be handling which meds are safe to stop, and which are vital to remain. I've never seen psychiatrist on the list of job openings. Not even a PMHNP. Nothing. Lately I've been fired up enough about this that truly, I am considering running this up the chain. I know we are limited in some ways, being in a rural area, but I've had instances that feel borderline unsafe or inadequate by far, and that bothers me.

Rural areas are using either tele-psych or phone consult liaison in many cases which is helpful for psych med regimens. When it comes to just alcohol or drug detox psychiatry shouldn't be needed as medical floors should, imo, have the knowledge and resources to handle those patients safely.

[Lev, MSN, RN, NP]

I'm not sure if I understood you but with most antipsychotic meds the risk of abrupt discontinuation is not withdrawal symptoms as much as causing the patient to psychiatrically decompensate. A schizophrenic patient for example generally should not be taken off their medications if their isn't a medical indication.

You are right about the antipsychotics. I was thinking of some of the antidepressants and increased risk of suicide when people are put on the meds or with dose increases.

The rate of suicide in the schizophrenic population is comparatively high. This may have to do with med compliance. Not sure though.

[dpappasRN1207]

We use CIWA at our hospital as well. We initiated about 5 years ago between our intensivist team and Critical Care Education. I was thrilled. I had been saying for years when they kept dumping the DT's on our ICU that it wasn't the ICU nurse's responsibility to play detox nurse! Drug and ETOH withdrawals were severely undermedicated for years, in my opinion. (We don't have an inpatient psych our chemical dependency unit. Our ICU gets them.) I generally like the protocol and that our patients suffer less. We use Ativan or Precedex. As another poster said, the main thing with Precedex is VS monitoring. We commonly will start a pt about to wean from the vent on low dose of Precedex w/o any worries of sedation or respiratory depression. The only issue I have is that sometimes when you have a pt really out of it or intubated, and then CIWA tends to shift more to the physical of what you can see, rather than ask. Sometimes it can be hard to get a reliable answer, especially if the pt is severely confused. Overall though, this is a huge step up from years ago when drs were too afraid to treat them. Now I'm trying to educate the nurses to not be afraid of sedation in these cases. Do many still are too afraid to use benzos in sedation. But Precedex works very well too. I've seen success with both meds.

[Smartin15]

We use CIWA in our ICU. Most of the time patients that are withdrawing are placed on preceded if it gets bad or phenobarbital but we have CIWA protocol as well. Our nurses are educated on the use of CIWA mostly by other nurses that are familiar with how it works. I haven't seen any hospital education for the use of the CIWA scale. It works when used properly however there are times when preceded is needed in addition to CIWA. Intubation is not necessary with preceded, but that depends on the patient and how they are responding. We have intimated these patients in the past but again it all depends on the patient.