Nursing Model Research Paper

IMPROVING THE CARE OF OUR ALCOHOL DETOX PATIENTS 2
IMPROVING THE CARE OF OUR ALCOHOL DETOX PATIENTS 24

Improving the care of our alcohol detox patients
Donnell Stewart
Anderson University

Running head: IMPROVING THE CARE OF OUR ALCOHOL DETOX PATIENTS 1

Today?s healthcare environment calls for continued cost containment while providing better, quality care. As a result of the advances of healthcare, life expectancies have increased resulting in a growing, aged population with more chronic conditions. Treatment options, outside the hospital, are the norm for most routine management of patient care, but when someone gets sick, and requires hospitalization, the combination of their age, chronicity of illness and increased comorbidity

result in a much sicker patient. The use of drugs and alcohol further complication the management of patients with chronic conditions as their withdrawal from these substances can be mistake as something else, especially if they are unable to communicate the use of these substances, and symptoms of withdrawal, to healthcare providers.
With this as a backdrop, the nurses of the 7Southwest (7SW) medical unit at St. Vincent?s Hospital, Indianapolis, began to question the management of our alcohol detox patients and the validity and usefulness of the standard alcohol withdrawal scale used to manage these patients. The nurses of 7SW and St. Vincent?s are not alone with regards to the challenges we have with patients experiencing AWS, in that: there not being a uniform process (e.g. different tools/processes used to determine whether they are experiencing withdrawal depending on where you work), there?s been no standardized training of nurses regarding alcohol withdrawal, Clinical Institute Withdrawal Assessment (CIWA) and the various ways in which we care for these patients, and finally, CIWA being used in areas that it?s not appropriate (e.g. ICU, surgical units, etc.).
The paper that follows will: 1. review the problem of alcoholism & alcohol withdrawal, 2. recount the present management of this patient population, 3. discuss challenges faced in working with these patients, and 4. suggest some changes to processes, that will result in more appropriate care for these patients.
Review of Literature
Problem: Alcoholism
?Alcohol is the most commonly abused substance in the United States, and 8.2 million Americans excessively consume alcohol? (Phillips, Haycock, & Boyle, 2006, p. 191). Excessive alcohol use, also known as binge drinking, is defined as >4 drinks for women and >5 drinks for men. The use of alcohol, thought to be the third-leading preventable cause of death in the US, is associated with a myriad of physical ailments (i.e. cirrhosis, cancer, unintentional injuries, violence and fetal alcohol syndrome) and increased costs related to loss of life, productivity, individuals? earnings potential, and increases in healthcare cost, property damage, the criminal justice system cost (Bouchery, Harwood, Sacks, Simon, & Brewer, 2011, p. 516). The CDC notes that excessive alcohol use kills 79,000 people yearly in the US. Reportedly, excessive drinking cost every man, woman, and child, in the US $746 ($223 billion), in 2006 (Centers for Disease Control and Prevention website, n.d.). This cost continues to increase from early estimates of less than 100 billion dollars through the 1980?s (About.com website, n.d.), almost 200 billion in 1998 (Harwood, 2000) and is thought to grow conservatively at a rate of 3% (Bouchery et al., 2011, p. 521) to 3.8% (Harwood, 2000, p. 1). While these estimates are difficult to establish (Harwood, 2000), it is thought that healthcare cost make up the second largest portion of the total cost (i.e. 26.3 billion) (10th Special Report to US Congress on Alcohol & Health, 2000, p. 366). Phillips, et.al, notes that 15-20% of all primary care/ hospitalized patients are dependent on alcohol, 25% of patients withdrawing have seizures, 50% of trauma patients have a history of alcohol abuse, and alcoholism is associated with more trauma, requiring intensive care management, and related death than other comorbid disease processes (Phillips et al., 2006, p. 191). Finally, Bouchery, et.al, noted specifically that, of the 24.6 billion dollars spent on healthcare cost, and that the government (i.e. taxpayers) bear the majority of the cost associated with excessive alcohol use (e.g. 42.1% or 94.2 billion vs. 41.5% or 92.9 billion) (Bouchery et al., 2011, p. 520).
Clinical presentation and negative outcomes of alcohol withdrawal syndrome (AWS):
Alcohol withdrawal is defined as a combination of subjective and objective clinical findings in the DSM-IV, reported following the cessation or reduction in heavy or prolonged alcohol use (McKeon, Frye, & Delanty, 2008, p. 855), coupled with distress and impairment in social and occupation functions that can?t be attributed to a medical or psychiatric condition result in a diagnosis of AWS (McKay, Koranda, & Axen, 2004, p. 16). See Table 1.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Criteria for alcohol withdrawal

A. Cessation of (or reduction) in alcohol use that has been heavy or prolonged

B. Two (or more) of the following, developing within several hours to a few days after criterion A

Autonomic hyperactivity (e.g. changes in vital signs)

Increased hand tremor

Insomnia

Nausea or vomiting

Transient hallucinations

Psychomotor agitation

Anxiety

Grand mal seizures

C. Criterion B symptoms cause significant distress or impairment in social, occupational or other important areas of functioning

D. Symptoms are not due to something else (e.g. general condition or another mental disorder).

TABLE 1. Sarff, M., & Gold, J. A. (2010). p. 495.

The symptoms are the result of physiologic changes in the functioning of various neurotransmitters and receptors (i.e. gamma-aminobutyric acid type-A (GABA-A) and N-methyl-D- aspartate (NMDA) receptors, dopamine, serotonin, glutamate norepinephrine, ?-endorphin, corticotropin-releasing factor and catecholamines) and as a result can complicate appropriate diagnosis (Bayard, McIntyre, Hill, & Woodside, 2004; Bostwick & Lapid, 2004; Chabria, 2008; McKeon, Frye, & Delanty, 2008; Sarff & Gold, 2010; & Spies & Rommelspacher, 1999).
Alcohol withdrawal can be thought of as occur in stages: stop/ decrease drinking autonomic hyperactivity hallucination neuronal excitation (seizures) delirium tremens (Sarff, M. & Gold, J.A.,2010), but not everyone?s experience of withdrawal progresses in the same fashion, and appropriate management can decrease the likelihood of progression past the autonomic hyperactivity stage. With early use of alcohol, withdrawal is likely not to be as severe, but with each subsequent experience of withdrawal a condition known as kindling can occur and result in subsequent experiences of withdrawal beginning more severe (Foy et al, 1997, Sarff & Gold, 2010 & Spies et al, 1999). Subsequent experiences of untreated withdrawal can lead to patients experiencing more severe symptoms: hallucinations, seizures and delirium tremens, which are associated with increased morbidity, mortality and increased length of stay, especially when coupled with patients that have comorbid conditions (McKay, et al 2004, Monte et al, 2010, & Stehman & Mycyk, 2013). See Table 2.
Autonomic hyperactivity-all cases
Hallucinations-
25-30% of cases
Seizures-
10% of cases
Delirium tremens-
5% of cases

Onset 6-24/48hrs
Onset 8-48hrs
Onset 12-48hrs
Onset 48-72hrs

Sx: diaphoresis
Visual
Tonic clonic
Autonomic hyperactivity

N&V
Tactile
Single or multiple
Hallucinations

Anxiety/ Agitation/ Tremor

Not sustained status epilepticus

TABLE 2. Sarff, M., & Gold, J. A. (2010). p. 495 & Stehman & Mycyk, (2013).

Management of Alcohol withdrawal
As stated previously, alcohol withdrawal is a growing concern as alcohol use/ misuse has been identified as a concern for an increasing number of patients that present to the hospital. The management of these patients, (e.g. ?stabilization of the autonomic nervous system by keeping the patient?s symptoms within the parameters of no autonomic hyperactivity and no respiratory depression?, McKay et al, 2004) while different to some extent (e.g. depending on history of use, past experience with withdrawal, comorbid conditions, etc.), can be best achieved by the use of a bundle. The Institute for Healthcare Improvement notes, ?A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices?? generally three to five?? that, when performed collectively and reliably, have been proven to improve patient outcomes? (http://www.ihi.org/resources/Pages/ImprovementStories/WhatIsaBundle.aspx). Upon review of the literature it seems evident that the bundle would include the following:
Alcohol withdrawal bundle

Identify use the CAGE questionnaire or talk with family/ support system to determine that the patient might have an issue with alcohol

Monitor Use some type of withdrawal scale to determine when patients is experiencing withdrawal symptoms (e.g. CIWA or some modified version?depends on population you are treating)

Treat Use benzodiazapines via dosing a symptom triggered (e.g. withdrawal scale score triggers predetermined dose of medicine) regimen. Use other meds as needed (e.g. antipsychotics, antiepileptics and cardiac meds).

Support Provide nutritional supplementation, fluid resuscitation (per protocol), quiet/ low stim environment to promote rest, reality orientation and reassurance.

Follow up care encouragement or linkage to follow up with others that can help patient maintain soberity (e.g. Alcohlics Anonymous and others)

TABLE 3.
It seems it should go without saying that the place to start with managing alcohol withdrawal would be to have first identified this as a potential current concern. Many authors have noted this as an important starting point, and use a quick tool called the CAGE assessment (e.g. four simple questions to be answered by the patient), but many miss this step completely. (Spies et al 1999, Stanley et al, 2003, May et al, 2004). This identification step is also hampered by a patient the presents who is unable to cooperate with answering questions and thus family, friends and other supports might need to address these issues on the patients behave. Other assessments that might be used to identify alcohol use as a problem include the Michigan Alcohol Screening Test (MAST) and the Alcohol Use Disorder Identification Tool (AUDIT) (Repper- Delisi et al., 2008).
Once alcohol use is identified as a problem a more in depth tool should be used to determine if, and when, the patient is experiencing withdrawal. The CIWA scale was the result of adaptations made to the Selected Severity Assessment, which was a shortened version of the Total Severity Assessment (Foy et al, 1997), has been further adapted: CIWACIWA- ACIWA-AD CIWA- Ar and is used to evaluate a patients current state of alcohol withdrawal. Some authors noted this assessment as objective (Foy et al, 1997; Kahn et al, 2005; Kahan et al., 2005; Stanley et al., 2003; Hecksel, Bostwick, Jaeger, & Cha, 2008), but the CIWA consist to ten, mainly subjective, complaints (i.e. nausea and vomiting, anxiety, tactile, auditory and visual disturbances, headache and orientation) that the patient must be able to speak to?if not, the tool is useless (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989). The CIWA scale is thought to be the gold standard, but there is disagreement regarding this in the literature. While the CIWA has been used in a variety of settings, it has only been validated, and deemed reliable, with patients that were not medically complex (e.g. just dealing with alcohol withdrawal), that are lucid, and as stated recently able to answer questions (e.g non-medically complex inpatient and outpatient patients) (Sullivan et al, 1989); Despite these requirements various studies have attempted to show the tools application in inpatient settings and sometimes with poor results for patients (Kay & Taylor 1997, Bostwick et al, 2004, Weaver et al, 2006, Kahan et al, 2005 and Sarff et al, 2010). Some have attempted to modify the CIWA scale further (Benson, McPherson & Reed, 2012; Graffenred, et al, 2004), while others have come up with their own scale/ tool adding items that that think will better enable them to identify alcohol withdrawal in patients that it would be inappropriate to use the CIWA scale with (Stanley et al, 2003 and Wetterling et al, 2006). No matter what scale is used, scales are beneficial to: aid with the diagnosis of withdrawal, indicate when med might be needed, alert staff in the patient condition is deteriorating or improving (Williams, et al 2001).
Benzodiazepines (benzos) have been identified as the best medical choice to aid patients with the succession of alcohol withdrawal symptoms (McKeon et al, 2008, Repper- Delisi et al., 2008; Sarff & Gold, 2010; Weaver et al, 2006). Other medications have been evaluated for management of alcohol withdrawal, but in the end benzos were identified as the best choice as they decrease neural activity?one of the early issues to be addressed in patients experiencing withdrawal. While there has been debate over the particular type of benzos (e.g. long acting vs. short acting), most of the literature now speaks to shorter acting benzos, like Ativan, now being the med of choice. The use of shorter acting benzos is thought to be advantageous for the following reasons: 1. Multiple means of delivery (i.e. PO, IM and IV), 2. Less problematic for patients that have issues that result from chronic alcohol use (e.g. liver dysfunction) and 3. Ease of use with an assessment tool, like CIWA, that results in a symptom triggered (e.g. medication based on score) treatment that can results in the management of some patients without the need for meds?supportive care only. Additionally, this symptom triggered treatment approach has been found to result in less medication being given and decreased length of stay (LOS) (McKay et al, 2004; McKeon et al, 2008, Sarff & Gold, 2010; Weaver et al, 2006). All that being said, there might be times when other treatment management, like fixed scheduled dosing of longer acting benzos might be appropriate (e.g. withdrawal severity, comorbid conditions and history of seizures, DT?s, etc.) (Benson, McPherson, & Reed, 2012). The use of this strategy is thought to result in a smoother detox experience for patients, but can also result in more medication being administered and longer LOS (Spies & Rommelspacher, 1999). Some opted for this option has opposed to symptom triggered citing poor education of staff using CIWA type and the potential complications that can result (Repper- Delisi et al., 2008). Low risk patients managed using symptom triggered regimen, high risk patients using fixed schedule regimen (Grafenreed, et al. 2004).
Other medications are used to support patients? other complications that might result due to alcohol use (e.g. psychosis, seizure disorder and cardiac issues). (McKeon, et al. 2008; Repper- Delisi et al., 2008, Myrick & Anton, 1998) Arrhythmias common in alcoholic patients (even without normal cardiac history) (Monte, et al. 2010). Antiepileptics (e.g. carbamazepine, oxcarbazepine, valproic acid, lamotrigine and topiramate looked at as standalone treatment, not found to be help in managing alcohol withdrawal by themselves, but help with decreasing seizure threshold. Beta blockers and clonidine used to decrease pulse, blood pressure and tremors and neuroleptics used as adjunct with benzos to decrease agitation and perceptual disturbances. (McKeon, et al. 2008).
As a result of alcohol use, patients experiencing alcohol withdrawal can present with various stages of nutritional/ fluid deficiency, need sleep and rest, physical comfort promoted and management of nausea, vomiting, diarrhea, and pain. Supportive care is a broad term noted to include such interventions as: vital signs monitoring, nutritional supplementation, fluid resuscitation, quiet/ low stim environments, reality orientation, reassurance, physical comfort, and positive encouragement towards sobriety (McKeon, et al, 2004; Wartenberg et al, 1990; Repper-Delisi et al, 2008). The use of supportive care involves both medicinal and non-medicinal means of addressing concerns that can lead to lengthening or worsening AWS. In those responding to supportive care alone, the CIWA score dropped rapidly. Shaw, et al., noted that three quarters of hospitalized patients, with moderate to severe withdrawal, but without serious medical complications, in alcohol withdrawal responded to intensive supportive care (Shaw, et al, 1981.). Detox protocols, that include nutritional supplements and fluids as part of a detox order set, are also helpful in insuring that this supportive care issues are addressed. Increased mortality and development of Wiernekes encephalopathy is thought to be associated with the failure to give adequate thiamine replacement, as ?thiamine is a coenzyme in glucose metabolism? and, low potassium has been associated with the development of DT?s (Lee, et al 2005, Eyer et al., 2011), or not (Monte et al., 2010), but if electrolyte replacement is needed, it should be accomplished via normal diet and fluid intake (McKeon et al, 2008).
The final piece to managing patients with alcohol withdrawal is follow up care. Follow up care involves group work (e.g. AA, therapy, etc.) and is only appropriate for those in the preparation stage of change (www.prochange.com, n.d.). Ultimate goal is to prevent further use of alcohol with subsequent episodes of alcohol withdrawal. Kahan et al note that ?physicians should express concern, suggest treatment options such as Alcoholics Anonymous or naltrexone, and advise family physician follow-up? with 10-40% of patients actually following up (Kahan et al, 2005; Wartenberg, et al. 1990). See Table 3.
Modified CIWA, other alcohol withdrawal scales and why we choose to take another look at the significance of vital signs
Vital sign changes are associated with earlier stages of alcohol withdrawal, but in patients with co-morbid conditions, it can be difficult to ascertain whether the change in vitals are the result of withdrawal and not the co-morbid condition that patient also suffers from. In addition to medical conditions complicating the patient?s presentation management of these medical conditions (e.g. hypertension, diabetes, infection), typically with medication, can result in the suppression of vital signs, and result in treatment delays and complications. (Roffman & Stern, 2006). Pulse and temperature were used in scoring of Selected Severity Assessment Scale (SSA) that was adapted and resulted in the CIWA (Shaw, et al, 1981). The issue with not using vital signs in withdrawal assessments resulted from the work of Sullivan et al (developers of the CIWA-Ar); In that work, the authors noted that ?pulse and blood pressure didn?t correlate at all with severity of withdrawal? the authors did note, however, that vitals are elevated in withdrawal but that ?the best predictors of high withdrawal score included groups of symptoms rather than individual symptoms? (Sullivan et al, 1989, p. 1355). It should also be noted that the patients in the Sullivan study were patients from a 20 bed detox unit (e.g. not medically complex) (Sullivan et al., 1989), and that chronic stable medical conditions were not associated with a statistically significant increased risk of DT?s (Fiellin et al., 2002); All of this to say, ?the scale is of most use in the usual clinical care of patients in alcohol withdrawal? (Sullivan et al., 1989, p. 1355). Sweating and anxiety had the highest correlation with total CIWA-Ar score (Sullivan et al, 1989) likely associated with elevated vital signs. Despite their lack of concern with vitals indicating worsening withdrawal symptoms, vital signs are noted on the CIWA-Ar, included in discussion of diagnosis in DSM and thought to be an indicator of withdrawal.
While the work of Sullivan et al didn?t find vitals a significant indicator of withdrawals others have. Blood pressure was found to be higher in case patients? and those patients that experienced delirium tremens (Fiellin, O?Connor, Holmboe & Horwitz, 2002; Monte, Rabunal, Casariego, Bal & Pertega, 2009). High pulse rates of admission, along with previous history of DT and decreased potassium levels where predictive of DT?s (Lee et al., 2005) and finally, Stehman & Mycyk?s work in the ED resulted in a call for treatment of alcohol withdrawal patients that used a modified CIWA, and until then to ?pay attention to mental status and vital signs?, noting sedation and abnormal vitals as an indicator of some other issues (e.g not withdrawal and the sedation with easy arousal and normal vitals as appropriately treated alcohol withdrawal (Stehman & Mycyk, 2013, p. 738). The works of Stanley et al. (2003), where AWS that includes vital signs as part of scoring resulting in medication administration, Wetterling, et al. (2006), who developed the Luebeck Alsohol Withdrawal Risk Score (LARSII) where pulse is included in the tool and correlated with predicting alcohol withdrawal and Grafenreed, et al, (2004) and their Sedation-Agitation Scale (SAS) that is a combination of symptoms of withdrawal, the CIWA-Ar and is used in the ICU are just a few examples of alternative scales developed to assess for AWS.
The validity of CIWA-Ar use, in the acute care hospital, is not the only area of concern for this tool. While only noted via a single study, CIWA-Ar is also called into question as a valid tool when used with Native Americans and those of a lower socio- economic status (Rappaport etal., 2013, p. 3), but an investigation of the validity of the tool from this perspective is beyond the scope of this study.
So with this variety in scales and problems with tis use in the acute, co-morbidly ill patient: why is CIWA still being used? The answer to this, as Saraff & Gold point out is simple and unfortunate: CIWA, ?because of its ease of use has often been expanded to other groups of patients not represented in the initial validation studies? (Sarff & Gold, 2010, p. 497).
Theoretical Framework
The Professional Practice model, designed by St.

Vincent nurses, provides a framework for professional nursing practice guided this research. As the business of healthcare is about taking care of people, the model starts with the patient, and their family, as the central focus. Surrounding the patient, are the concepts of mind, body and spirit, which cause us to think holistically regarding the care provided. Finally, the core values/ faith based practices, guide us in managing our patients in a way that is consist with our culture/ values, supportive of our professional growth, encourages the use of best practices, that result in better outcomes, and makes us productive in a way the encourages giving back outside the hospital as well (Stone, 2011).
No matter where care is being provided the nurses foremost concern should be the patient. Work with patients should be holistic in nature such all aspects of their person are provided appropriate care (e.g. nursing, counseling and spiritual). The problem excessive alcohol use in an older, chronically ailing population results in a situation where nurses must continue to learn about and apply best practices, to strive for better outcomes with these patients and, if truly passionate/ learned enough about this topic assist them outside the hospital as

well.
Methodology
Nurses on 7Southwest (7SW) will be provided education regarding alcohol withdrawal, a review of the current tools/processes (CIWA-Ar and order set) and new tools/processes (Modified CIWA-Ar and order set). At the end of this education, role playing will be used to facilitate use of the Modified CIWA-Ar, with discussion of scoring using the tool and evaluation for inter-rater reliability. After this education the modified tool and order set will be used. A retrospective chart review will be conducted on 7SW patients charts for a period six month before and six months after the education to determine the quantity of Ativan used and LOS for each patient. Additionally, a pre and post survey will be taken by the 7SW nursing staff to gauge their satisfaction with the change in the tool and process for managing AWS (Appendix C). It?s hypothesized that the review will bear out that Ativan use and the average patient LOS have decreased, due to better understanding of alcohol withdrawal syndrome (AWS) and management of AWS via a scale that is sensitive to vital signs changes?an early indicator of withdrawal. With use of this Modified scale, earlier intervention/ treatment will occur, resulting in the decreased development of complications that result from a delay in care. Nurse satisfaction is thought to also improve as more objective symptoms (e.g. vitals signs) will be use to evaluate patients that can?t sometime participate in their assessment in the manner required with the CIWA scale.
Sample
Inclusion criteria would include all patients on 7SW, for a period of 180 days, prior to and following the education of staff, that have a diagnosis that includes alcohol abuse, dependence or withdrawal, is maintained on the alcohol detox protocol and discharged from our floor. Exclusion criteria would include, all patients on 7SW for a period of 180 days, prior to and following the education of staff, which do not have a diagnosis that includes alcohol abuse, dependence or withdrawal, not maintained on the alcohol detox, or maintained on detox protocol but transferred to a higher level of care (e.g. ICU). Finally, patients that were unable to coherently communication will be excluded as the new tool in predominately the CIWA, which in requires patient to answers questions, with vital sign added as scoreable items. Co-morbid medical conditions are not exclusionary criteria for this study, but patients with drug dependence other than alcohol and experiencing seizures, hallucinations and delirium tremens were.
Approximately twenty-five nurses will participant in the part of the study that is concerned with nursing satisfaction. Nursing staff will consist of only that group of nurse that normally works on 7SW, range in age from earlier twenties to mid-sixties and nursing experience that ranges from six months to thirty-eight years.
Setting
An eleven bed, medical/ psychiatric floor house on the seventh floor (7SW) of St. Vincent Hospital in Indianapolis, IN. St. Vincent Hospital and Health Center is a 903-bed general medical and surgical facility with 35,300 admissions in the most recent year reported. It performed 11,138 annual inpatient and 13,746 outpatient surgeries. Its emergency room had 82,390 visits. St. Vincent Hospital and Health Center is a teaching hospital (http://health.usnews.com/best-hospitals/area/in/st-vincent-hospital-and-health-center-6420715).
Concepts/ Variables
Concepts and variables would include 7SW nursing staff current understanding of alcohol withdrawal syndrome (e.g. pathophysiology, treatment, orders sets, scales used to assess patients), the role of vital signs in determining a patient?s stage of alcohol withdrawal, the use of a standard order set/detox protocol and symptom triggered dosing of meds, the nurses understanding of the CIWA-Ar and satisfaction with this scale, and the role of early intervention with supportive care then meds (benzodiazepines) to prevent a more severe case of AWS that will result in increased nursing care, amounts of medication and patient length of stay. A pre and post survey of the aforementioned items will be conducted to determine nursing staff understanding of the above mentioned concerns. A retrospective chart review will demonstrate the amount of Ativan used and LOS for patients pre and post the educational intervention.
Design
This study will be mixed (e.g. Quasi- experimental & Qualitative) in nature. The quantitative portions will be determined as reliable and valid by statistical methods determined best suited for this project by one of the St. Vincent biostatisticians. The qualitative concern (e.g. nursing satisfaction) will be demonstrated via comparison of nurses answers to a survey and the percentage of change noted after the educational intervention, but will also include regression analysis of the determinants of job satisfaction according to this equation: JS=(f) ?1KNOW (+),??2CIWA(+), ?3ATIVAN(+), ?4LOS(+), ?5DETOX(-), ?6UNIT(-), ?7YEARS(+).

Ethical Considerations
St. Vincent?s Internal Review Board (IRB) approval will be obtained prior to education of 7SW staff nurses and collection data (see Appendix C&D). No risks for staff or patients were identified as staffs were just being questioned regarding their satisfaction with their part in the management of our alcohol withdrawal patients (e.g. using the CIWA scale vs. Modified CIWA scale and corresponding order set). Changes in the order set (e.g. Ativan dosing based on the new scale score were recommended per the Stress Center Medical Director (e.g. Chief of Psychiatry) were determined to result in an equivalent dosing of Ativan and management of our alcohol detox patients. A review of potential ethical considerations was facilitated via the use of the Anderson University Human Research Participants Proposal Form. Informed consent was provided to all staff nurses, and acknowledged via signature, prior to completion of the nursing satisfaction survey. Informed consent for our patients was not needed as the study will result in an equivalent treatment of our alcohol detox patients. No identifying information will be gathered to protect the privacy of our patients and staff.
Conclusion
Alcoholism is a growing problem in our society. The use of alcohol to excess presents a variety of negative consequences for those that partake of it in this manner. Excessive alcohol use can result in complications that cause the person drinking to need to visit the hospital (e.g. withdrawal, worsening of a chronic condition or trauma). Once at the hospital, the patient should be screened for excessive alcohol use via the CAGE assessment and then a more thorough assessment conducted. The more thorough assessment should include a history of recent alcohol use, including last drink, normally use pattern and negative consequences that result from their drinking needs to be evaluated?the family should be questioned regarding this if the patient is unable to speak to this. If determined to be at risk for AWS, patients should be monitored via trained staff, using a symptom triggered scale (a modified CIWA-Ar that incorporates an objective measure like elevated vital signs precursor to negative outcomes of AWS and included in the DSM- IV diagnostic criteria) and medicine (Ativan) being given based on a score that elevated vital signs contribute to ?detox protocol? that will help to ensure that the majority of patients? receive early intervention/ management of their withdrawal symptoms while the evaluation and management of other conditions/ complications are addressed. This detox protocol-- with call orders-- that includes supportive care measures (e.g. low stimulation, fluids and nutritional support). Finally, better hand-off/ discharge planning should be performed in an effort to link these patients to care providers that can further assist them in the maintenance of their sobriety.
At St. Vincent?s, we have employed the majority of this process in the past, but believe the use of a Modified CIWA (e.g. including all the components of the current CIWA-Ar, but making elevated vitals a scoreable component of the tool) will result in our being able to use this technique more appropriately in the majority of the hospital, but recognize as the literature points out, that some areas of the hospital (e.g. ICU & ED) might call for an even more tailored and individualized approach (e.g. fixed scheduled dosing, plus symptom triggered for breakthrough). The problem with using the CIWA-Ar in most inpatient areas of the hospital lays in the fact that the CIWA assessment requires that patient to ?have clear sensoria to reply logically to (subjective) questions? (Hecksel, et al, 2008, p. 274), and this is often not the case with a patient presenting to the hospital with comorbid conditions. By modifying the CIWA-Ar, and including objective signs (e.g. changes in vital signs) as scoreable, like others have, we believe this tool will be found to be more valid and reliable and help us continue to manage our patients safely (e.g. not experiencing as severe a withdrawal and receiving less Ativan) and efficiently (e.g. with a decrease in their length of stay). Lastly, it?s thought that the use of the Modified CIWA will result in increased nurses? satisfaction because it includes vitals as a scoreable component of the tool and have a better understanding of alcohol withdrawal and how it is managed.
The major limitation in this study lies in the area known as confounding. In patients that have co-morbid illnesses (e.g. hypertension) you may not necessarily know that your treatment is related to alcohol withdrawal alone and not the illness. As mentioned previously, the original research was conducted in a detox center and medically complex patient presentations excluded the patient from the study, so alcohol withdrawal was the only possible cause for increases in the subjective findings that patients complained of.
If this study is successful we hope to try this tool out in other area of the hospital, medical- surgical floors first, and then, move towards other areas as deemed appropriate.

References
10th Special Report to US Congress on Alcohol & Health (10th ed.). [Adobe Digital Editions]. (2000). Retrieved from pubs.niaaa.nih.gov/10Report/10thSpecialReport.pdf
About.com website. (n.d.). http:// alcoholism.about.com/cs/alerts/l/blnaa11.htm
Bayard, M., McIntyre, J., Hill, K. R., & Woodside, J. (2004, March). Alcohol Withdrawal Syndrome. American Family Physician, 69(6), 1443-1450.
Benson, G., McPherson, A., & Reed, S. (2012, June 26). An alcohol withdrawal tool for use in hospitals. Nursing Times, 108 (26), 15-17.
Bostwick, J. M., & Lapid, M. I. (2004, May-June). False Positives on the Clinical Institute Withdrawal Assessment for Alcohol- Revised: Is This Scale Appropriated for Use in the Medically Ill? Psychosomatics, 45, 256-61.
Bouchery, E. E., Harwood, H. J., Sacks, J. J., Simon, C. J., & Brewer, R. D. (2011). Economic Cost of Excessive Alcohol Consumption in the U.S., 2006. American Journal of Preventive Medicine, 41, 516-524.
Centers for Disease Control and Prevention website. (n.d.). www.cdc.gov/features/alcoholconsumption
Chabria, S. B. (2008). Inpatient management of alcohol withdrawal: a practical approach. Signa Vitae, 31, 24-29.
Delisi, J. R., Stern, T., Mitchell, M., Cushing, M. L., Lakatos, B., Fricchione, G., ... Bierer, M. (2008). Successful Implementation fo an Alcohol Withdrawal Pathway in a General Hospital. Psychosomatics, 49 (4), 292-299.
Eyer, F., Schuster, T., Felgenhauer, N., Pfab, R., Strubel, T., Saugel, B., & Zilker, T. (2011). Risk Assessment of Moderate to Severe Alcohol Withdrawal-- Predictors for Seizures and Delirium Tremens in the Course of Withdrawal. Alcohol and Alcoholism, 46 (4), 427-433.
Fiellin, D. A., O?Connor, P. G., Holmboe, E. S., & Horwitz, R. I. (2002). Risk for Delirium Tremens in Patients with Alcohol Withdrawal Syndrome. Substance Abuse, 23 (2), 83-94.
Foy, A., McKay, S., Ling, S., Bertram, M., & Sadler, C. (2006). Clinical use of a shortened alcohol withdrawal scale in a general hospital. Interanl Medicine Journal, 36, 150-154.
Grafenreed, K.

M., Lobo, B., Sands, C., & Yates, M. (2004, June 1). Development of an alcohol withdrawal delirium prophylaxis protocol in a community teaching hospital. American Journal of Health- System Pharmacist, 1151-1155.
Harwood, H. (2000). Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
Hecksel, K., Bostwick, M., Jaeger, T., & Cha, S. (2008). Inappropriate Use of Symptom- Triggered Theraphy for Alcohol Withdrawal in the General Hospital. Mayo Clinic Proceedigns, 83 (3), 274-279.
Kahan, M., Borgundvaag, B., Midmer, D., Borsoi, D., Edwards, C., & Ladhani, N. (2005). Treatment variability and outcome differences in the emergency department managment of alcohol withdrawal. Canadian Journal of Emergency Medicine, 7 (2), 87-92.
Lee, J. H., Jang, M. K., Lee, J. Y., Kim, S. M., Kim, K. H., Park, J. Y., ... Yoo, J. Y. (2005). Clinical predictors for delirium tremens in alcohol dependence. Hepatology, 20, 1833-1837.
McKay, A., Koranda, A., & Axen, D. (2004, February). Using a Symptom-Triggered Approach to Manage Patients in Acute Alcohol Withdrawal. MEDSURG Nursing, 13, 15-20,

31.
McKeon, A., Frye, M. A., & Delanty, N. (2008). The alcohol withdrawal syndrome. Journal of Neurology, Neurosurgery and Psychiatry, 79, 854-862.
Monte, R., Rabunal, R., Casariego, E., A, H. L., Mateos, A., & Pertega, S. (2010). Analysis of the Factors Determining Survival of Alcoholic Withdrawal Syndrome Patients in the General Hospital. Alcohol & Alcoholism, 45 (2), 151-158.
Monte, R., Rabunal, R., Casariego, E., Bal, M., & Pertega, S. (2009). Risk factors for delirium tremens in patients with alcohol withdrawal syndrome in a hospital setting. European Journal of Internal Medicine, 20, 690-694.
Monte, R., Rabunal, R., Casariego, E., Lopez-Agreda, H., Mateos, A., & Pertega, S. (2010). Analysis of the Factors Determining Survival of Alcoholic Withdrawal Syndrome Patients in a General Hospital. Alcohol & Alcoholism, 45 (2), 151-158.
Myrick, H., & Anton, R. F. (1998). Treatment of Alcohol Withdrawal. Alcohol Health & Research World, 22 (1), 38-42.
Phillips, S., Haycock, C., & Boyle, D. (2006). Development of an Alcohol Withdrawal Protocol. Clinical Nurse Specialist, 20, 190-198.
Rappaport, D., Chuu, A., Hullen, C., Nematollahi, S., Teeple, M., Bhuyan, N., ... Sanders, A. (2013). Assessment of Alcohol Withdrawal in Native American Patients Utilizing the Clinical Institute Withdrawal Assessment of Alcohol Revised Scale. Journal of Addiction Medicine, 00(00), 1-4.
Repper- Delisi, J., Mitchell, M., Lakatos, B., Quinlan, J., Berube, R., Capasso, V., & Karson, A. (2008). Successful Implementation of an Alcohol- Withdrawal Pathway in a General Hospital. Psychosomatics, 49 (4), 292-299.
Roffman, J. L., & Stern, T. (2006). Alcohol Withdrawal in the Setting of Elevated Blood Alcohol levels [Primary Care Companion]. Journal of Clinical Psychiatry, 8 (3), 170-173.
Sarff, M., & Gold, J. A. (2010). Alcohol withdrawal syndromes in the intensive care unit [Supplemental material]. Critical Care Medicine, 38(9), S494-501.
Schaefer, T. J., & Hafner, J. W. (in press). Are Benzodiazepines Effective for Alcohol Withdrawal. Annals of Emergency Medicine.
Spies, C. D., & Rommelspacher, H. (1999). Alcohol Withdrawal in the Surgical Patient: Prevention and Treatment. Anesthesia & Analgesia, 88, 946-54.
Stanley, K., Amabile, C., Simpson, K., Couillard, D., Norcross, D., & Worrall, C. (2003). Impact of an Alcohol Withdrawal Syndrome Practice Guideline on Surgical Patient Outcomes. Pharmacotheraphy, 23 (7). Retrieved from www.medscape.com
Stehman, C. R., & Mycyk, M. B. (2013). A rational approach to the treatment of alcohol withdrawal in the ED. American Journal of Emergency Medicine, 31, 734-742.
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of Alcohol Withdrawal; the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). British Journal of Addiction, 84, 1353-1357.
Tetrault, J. M., & O?Connor, P. G. (2008). Substance Abuse and Withdrawal in the Critical Care Setting. Critical Care Clinics, 24 (4), 767-88.
Wartenberg, A., Nirenberg, T., Liepman, M., Silvia, L., Begin, A., & Monti, P. (1990). Detoxification of Alcoholism: Improving care by Symptom- Triggered Sedation. Alcoholism: Clinical and Experimental Research, 14 (1), 71-75.
Weaver, M. F., Hoffman, H. J., Johnson, R. E., & Mauck, K. (2006, ). Alcohol Withdrawal Pharmacotherapy for Inpatients with Medical Comorbidity. Journal of Addictive Diseases, 25 (2), 17-24.
Wetterling, T., Weber, B., Depfenhart, M., Schneider, B., & Junghanns, K. (2006). Development of a rating scale to predict the severity of alcohol withdrawal syndrome. Alcohol & Alcoholism, 41 (6), 611-615.
Williams, D., Lewis, J., & McBride, A. (2001). A Comparison of Rating Scales for the Alcohol-Withdrawal Syndrome. Alcohol & Alcoholism, 36 (2), 104-108.
www.prochange.com. (n.d.). www.prochange.com

Reflective Journal
Research can be intimidating for the average nurse, but changes in healthcare now call for us all to become educated, consumers of information that can be analyzed and integrated into our care for patients, help the staff we work with and the organizations we work for. Through the use of research, the nurse can positively impact patient care at the bedside, unit, hospital and system level.
In writing this paper, I continued to be reminded of a few things I know about myself. First, I?m interested in research and have enjoyed the process of getting to know more about a problem?in this case alcoholism. Secondly, I?m interested in the use of good research to address concerns I, and others I work with, face in this changing healthcare environment. Being able to participate in a process that will bring about a positive outcome for our patients, and the overall organizations, results in a good feeling and encourages me to continue to pursue these types of efforts. Finally, I am a lifelong learner and look forward to participating in what will result in making a difference for the people (patients) and organizations I work for. All that being said, I hope the future affords me the opportunity to work as the leader of an organization that is constantly patient centered, looking to learn and focused on better outcomes.
Overall I have enjoyed the course but think the use of another text like Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice by Melnyk and Fineout-Overholt would have supported the students better in working through the process of writing our research paper. I?ve used an older version of this text, following its stepwise (chapter by chapter) process to complete another research paper I?d previously completed. Finally, I wish this course, or the MSN program required a statistics course/ component. I believe a statistics course should be taken in conjunctions with this course to truly round out the research work we?re doing. Just as nursing administrators are being pressed to have knowledge in the areas of business (e.g. accounting, finance, and human resources) nursing researchers should have an appreciation for the type of analysis that a nurse with a working knowledge of statistics can bring to bear on research; Not as an expert (biostatistician), but with a good basic understanding and knowledgeable enough to know where to go for further information, answer questions about what demonstrates good research and deciding how to set up a study; Understanding research in this way is a time saver and beneficial in the case that the researcher is conducting research that hasn?t been undertaken previously. Additionally, this knowledge will give me the ability to be more of a participant as I will have a more comprehensive understanding of the piece of research that makes it useful (e.g. the statistics (results).