case study 147 alcohol withdrawal quizlet

Slight intensification of mood

Slight impairment of judgment and motor skills

Tingling and numbness of face, hands, arms, and legs

Ataxia (imbalance and difficulty walking)

Impaired fine muscle coordination

Impaired mental abilities, judgment, attention span, and memory

More improvement in mood

Increased sociability and self-confidence

Euphoria

Delayed reactions

Staggering

Measurable effects on motor and emotional control centers

Loss of balance

Blurred or double vision

Urinary incontinence

Sedation

Amnesia

Amnesia

Vomiting (with the risk of pulmonary aspiration)

Reduced heart rate

Decreased circulation to extremities, causing cold or numb extremities

Respiratory depression

Depressed eye reflexes

Markedly decreased heart rate

Coma

Intervention

Signs and symptoms of AWS may cause fear and anxiety in both patients and family members. During the acute detoxification phase, the main goal of nursing care is to manage symptoms by keeping the patient safe and comfortable, giving drugs as ordered, and minimizing complications. Provide nonjudgmental supportive care, perform a general assessment, evaluate nutrition and hydration status, and implement the management protocol. Be sure to assess the patient’s risk for falls and seizures, and use precautions as indicated. If the patient must be restrained, assess skin around the restraints hourly for breakdown and provide treatment, if needed. However, avoid restraints whenever possible.

Patient monitoring

Patients with AWS should be admitted to a telemetry unit with pulse oximetry used to measure oxygen saturation (SaO2); administer oxygen if SaO2 falls below 92%. A patient with moderate to severe AWS may be admitted to the intensive care unit or critical care unit for close monitoring and care. Provide safety precautions according to facility policy.

Closely monitor the patient’s vital signs, heart rhythm and rate, respirations, fluid and electrolyte balance, blood glucose level, skin, elimination, mental and neurologic status, and nutritional status. Bleeding tendencies from liver damage may necessitate vascular volume substitution or blood transfusions if the patient’s iron and blood volumes are diminished. Beta blockers may be used to control hypertension and tachyarrhythmias.

Give ordered medications in a timely manner to decrease symptom severity and ease the patient safely through the detoxification period. Assess the patient for unstable mood, such as delirium, psychosis, depression, and suicidal or homicidal ideation.

Every hour the patient experiences AWS signs or symptoms, complete the CIWA-Ar scale and obtain vital signs. Used to evaluate the patient’s progress during alcohol withdrawal, the CIWA-Ar takes 5 to 10 minutes to complete. It helps reduce the risk of under- or overmedicating and evaluates the patient’s response to treatment. The clinician assigns a score of 0 to 7 in each of 10 categories. The maximum score is 67 points; the higher the score, the more severe the AWS symptoms. A score of 10 or lower indicates mild symptoms that usually don’t warrant medication. A score of 15 or higher suggests increased risk of seizures and DT. Patients who score 10 or higher should receive medications (such as benzodiazepines or anticonvulsants) according to the management protocol to decrease withdrawal symptoms, seizure risk, and DT.

Continue to administer the CIWA-Ar hourly and give medications as ordered until the CIWA-Ar score is below 10 for 3 consecutive hours. At that point, assess the patient and administer the CIWA-Ar every 4 hours; if the score rises above 10, resume hourly CIWA-Ar assessment. If needed, titrate medications as ordered and expect to withhold sedatives for lethargy, abnormal vital signs, or neurologic abnormalities.

Using an AWS protocol

Every healthcare facility should have a management protocol or standing orders for acute alcohol withdrawal so nurses can intervene appropriately without constantly consulting the physician. A hospital-approved protocol is a physician order sheet filled out and signed by the physician that allows nurses to use certain medications, treatments, and guidelines to treat patients. (See the box below).

Medications

Most alcoholics have a high alcohol tolerance and may require larger dosages or more frequent dosing of medications such as psychoactives (for instance, benzodiazepines), anticonvulsants, antiemetics, antiarrhythmics, antihypertensives, analgesics, and skeletal muscle relaxants, to suppress alcohol withdrawal effects. Otherwise, the patient may experience unwanted side effects from alcohol cessation and undertreatment. Be aware that failure to manage pain could make detoxification more difficult—or even fatal.

Benzodiazepines (such as diazepam, chlordiazepoxide, oxazepam, and lorazepam) are the drugs of choice for AWS if the patient is experiencing anxiety, agitation, restlessness, hallucinations, and seizure activity. However, benzodiazepines are addictive and must be used carefully to avoid cross-addiction.

Nurses who haven’t been educated in chemical dependencies may be uncomfortable giving medications according to the AWS protocol. An up-to-date in-service program and yearly hospital competencies for nursing staff can give them a better understanding of the protocol. Increased ongoing education can help them recognize AWS signs and symptoms, understand appropriate treatments, and ease their anxiety.

Increasing patient comfort

Implement measures as needed to make the patient more comfortable. To the extent possible, provide a quiet, dark environment by dimming lights, and limiting environmental stimulation. To keep body temperature comfortable, apply or remove blankets as needed and adjust room temperature. Offer fluids every hour while the patient is awake and record fluid intake.

Provide an appropriate diet as tolerated. During times of nausea or vomiting, restrict oral intake. If the patient has epigastric distress, encourage deep breathing and relaxation. Administer antiemetics as needed and offer ice chips, cool cloths, and a fan for comfort if the patient desires.

Change the patient’s position as needed and use pillows for support. Adjust the head of the bed often. Make sure the call light is working and the bed is in a low position. If the patient is restrained, check skin around the restraints hourly.

Check the patient’s temperature frequently. Allow rest or sleep between assessments. Avoid disturbing the patient, especially during the acute withdrawal phase. Help the patient to the bathroom and record output. Keep the patient oriented to time, place, and person. Place family photos and familiar items from home, as well as a clock and calendar, where the patient can see them. Provide reassurance, and reinforce the patient’s progress and positive elements of treatment. Allow only family visitors, but limit them if needed.

Provide education about alcohol abuse, dependency, and withdrawal to the patient and family to give them a better understanding of AWS and help them cope with the situation. Education can be verbal or provided by pamphlets, handouts, videos, and Internet sources. Additional education topics may include the risk that alcohol abuse could worsen associated diseases (such as infectious diseases, cancer, diabetes, neuropsychiatric disorders, cardiovascular conditions, and liver and pancreatic disease).

For optimal patient outcomes, use appropriate screening forms and the hospital-approved AWS protocol. Consult the dietitian and chaplain (if desired). Make appropriate referrals (such as to social services) so the patient can be treated appropriately for alcohol abuse or dependency.

Rita K. Driver is an adult clinical nurse specialist at Jackson Purchase Medical Center in Mayfield, Kentucky.

Selected references

Elliott DY, Geyer C, Lionetti T, Doty L. Managing alcohol withdrawal in hospitalized patients. Nursing . 2012;42(4):22-30.

Lee Memorial Health System. Adult ICU Alcohol Withdrawal Protocol Orders. http://www.leememorial.org/FormsManagement/PDF/PhysicianOrders/CriticalCare/3354AlcoholWithdrawal.pdf . Accessed May 8, 2013.

National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much. Updated 2005. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm . Accessed May 8, 2013.

National Quality Forum. National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices. Robert Wood Johnson Foundation; 2007. www.policyarchive.org/handle/10207/21566 . Accessed May 15, 2013.

Ng K, Dahri K, Chow I, Legal M. Evaluation of an alcohol withdrawal protocol and a preprinted order set at a tertiary care hospital. Can J Hosp Pharm . 2011;64(6):436-45.

Phillips S, Haycock C, Boyle D. Development of an alcohol withdrawal protocol: CNS collaborative exemplar. Clin Nurse Spec . 2006;20(4):190-8.

Pittman B, Gueorguieva R, Krupitsky E, Rudenko AA, Flannery BA, Krystal JH. Multidimensionality of the Alcohol Withdrawal Symptom Checklist: a factor analysis of the Alcohol Withdrawal Symptom Checklist and CIWA-Ar. Alcohol Clin Exp Res . 2007;31(4):612-8.

Rehm J. The risks associated with alcohol use and alcoholism. Alcohol Res Health . 2011;34(2):135-43.

Reiners G. Alcohol withdrawal assessment training protocol: a case study. J Nurs Care . 2012;1:5. omicsgroup.org/journals/2167-1168/2167-1168-1-118.pdf. Accessed May 8, 2013.

Riddle E, Bush J, Tittle M, Dilkhush D. Alcohol withdrawal: development of a standing order set. Crit Care Nurse . 2010;30(3):38-47.

Sirohi S, Bakalkin G, Walker BM. Alcohol-induced plasticity in the dynorphin/kappa-opioid receptor system. Front Mol Neurosci . 2012;5:95.

U.S. Department of Health and Human Services. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011. www.samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm . Accessed May 8, 2013.

3 Comments .

This article is a little outdated.

Alcohol withdrawal is common, but delirium tremens only occurs in 5% of people who have alcohol withdrawal. Delirium tremens is dangerous, killing as many as 1 out of every 20 people who develop its symptoms.

I’ve found diluting the alcohol with water has worked wonders. So far in the 2 months I’ve been doing this, there is much less confusion and alcohol related chaos. My friend has not noticed the difference and still enjoys what he drinks. I think the drinking is more out of habit and ritual than experiencing the effects of the alcohol at this point. Earlier this probably would not have worked with him.

Alcohol is really bad for health when it goes for a certain level and its also termed as addiction,some of friends are struggleing to come out from alcohol and after a long time later decided to quit,they are experiencing some symptoms,keep sharing this helpful article with us.

Comments are closed.

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Improving Nursing Knowledge of Alcohol Withdrawal

Second generation education strategies.

Berl, Kimberly MSN, RN, PCCN; Collins, Michelle L. MSN, RN-BC, ACNS-BC; Melson, Jo MSN, RN, FNP-BC; Mooney, Ruth PhD, MN, RN-BC; Muffley, Cheryl MSN, RN-BC; Wright-Glover, Angela MSN, RN-BC

Kimberly Berl, MSN, RN, PCCN, is a Staff Development Specialist for the Stepdown and Intensive Care Unit, Wilmington Hospital of Christiana Care Health System, Delaware.

Michelle L. Collins, MSN, RN-BC, ACNS-BC, is Director of Nursing Professional Development and Education, Christiana Hospital of Christiana Care Health System, Wilmington, Delaware.

Jo Melson, MSN, RN, FNP-BC, is a Nurse Practitioner, Wilmington Hospital of Christiana Care Health System, Delaware.

Ruth Mooney, PhD, MN, RN-BC, is a Nursing Research Facilitator, Christiana Care Health System, Wilmington, Delaware.

Cheryl Muffley, MSN, RN-BC, is a Staff Development Specialist for a Medical Stepdown Unit and the Express Admission Unit, Christiana Hospital of Christiana Care Health System, Wilmington, Delaware.

Angela Wright-Glover, MSN, RN-BC, is a Staff Development Specialist for two medical-telemetry units, Christiana Hospital of Christiana Care Health System, Wilmington, Delaware.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( www.jnpdonline.com ).

ADDRESS FOR CORRESPONDENCE: Kimberly Berl, MSN, RN, PCCN, Wilmington Hospital, 501 W. 14th Street, P.O. Box 1668, Wilmington, DE 19801 (e-mail: [email protected] ).

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0 .

Christiana Care Health System implemented a Care Management Guideline for Alcohol Withdrawal Symptom Management, which provided direction for inpatient screening for alcohol withdrawal risk, assessment, and treatment. Nurses educated on its use expressed confusion with the use of the assessment tools, pharmacokinetics, and pathophysiology of alcohol withdrawal and delirium tremens. Reeducation was provided by nursing professional development specialists. Pre- and postsurveys revealed that nurses were more confident in caring for patients with alcohol withdrawal.

The National Survey of Drug Use and Health, conducted from 2008 to 2012, reveals that 7.1% of Delawareans aged 12 or older describe themselves as dependent upon alcohol or abusive of alcohol in the previous year. In addition, 7.4% of these individuals considered themselves heavy users of alcohol, and yet only 3.8% received treatment—trends that are comparable to national averages ( Substance Abuse and Mental Health Services Administration, 2013 ). Throughout the nation, the number of adults admitted to a hospital with an alcohol use disorder increased significantly from 2006 to 2010 ( National Institute on Alcohol Abuse and Alcoholism, 2013 ), translating to approximately one in five admitted adult patients ( Elliott, Geyer, Lionetti, & Doty, 2013 ).

If untreated, up to 6% of patients with an alcohol use disorder will experience alcohol withdrawal when alcohol is withheld, with up to 10% of those progressing to delirium tremens (DT), a potentially life-threatening complication ( Melson, Kane, Mooney, McWilliams, & Horton, 2014 ). Screening and early management of alcohol withdrawal prevents progression of symptoms and further deterioration to DT ( Pecoraro et al., 2012 ). Before implementing the Care Management Guideline (CMG) for Alcohol Withdrawal Symptom Management, patients admitted to the largest healthcare system in Delaware were not evaluated for the potential of experiencing alcohol withdrawal, nor were they assessed or recognized until their behavior escalated to a crisis. The CMG for Alcohol Withdrawal Symptom Management is a hospital system tool developed by an interdisciplinary care team used to aid clinicians and providers in the management of this patient population. Prior to program implementation, severe symptoms arose before staff knew that patients were experiencing alcohol withdrawal. Delay in diagnosis and treatment resulted in suboptimal patient outcomes. Because of the absence of a protocol, patients experiencing escalating alcohol withdrawal were often transferred to an intensive care unit (ICU). Consequently, nurses and providers working outside of ICU were not prepared or educated to adequately manage the complexity of these patients.

The model of change that served as the framework of this process was Lewin’s change model. Kurt Lewin, a social psychologist, postulated a three-stage theory of change: unfreezing, change, and freezing or refreezing ( Lewin, 1947 ). For change to be successful, the driving forces for the change must be strengthened ( Shirey, 2013 ). For this project, such forces included safety considerations for nurses and patients, a desire on the part of the hospital to better manage patients with alcohol withdrawal, thus preventing DT and decreasing use of ICU and rapid response teams for this subset of patients. The nurses caring for patients experiencing alcohol withdrawal were unaware of the physiology of alcohol withdrawal and DT, and lacked confidence in caring for this patient population. They also felt that it would require more time to care for these patients, thus depriving other patients of their “share” of the nurse’s time. According to Lewin’s theory, these attitudes and beliefs are known as restraining forces, and these must be weakened in order for the change to occur successfully ( Shirey, 2013 ).

PHASE I: EDUCATION BEFORE IMPLEMENTATION OF THE CMG

Nursing professional development (NPD) specialists educated nurses and providers on the use of the new protocol before implementation. Education was provided by NPD specialists using small groups on individual patient care units, and larger groups of nurses from multiple units in a classroom setting.

There was much resistance to this initial education, both by NPD specialists and staff nurses. The short time frame designated for educating all of the nurses was challenging, and most NPD specialists had not previously used the Clinical Institutes Withdrawal Assessment-Alcohol revised (CIWA-Ar). The CIWA-Ar is a symptom-based assessment tool that quantifies the level of alcohol withdrawal symptoms, and helps determine appropriate Benzodiazepine dosing when the patient has a history of alcohol use. It is a freely distributed and widely used tool easily accessed via the Internet. The CIWA-Ar is widely used in both acute care and outpatient settings because of its high level of interrater reliability and ease of use. It is comprised of 10 questions and indicates the level of withdrawal the patient may be experiencing ( Sarff & Gold, 2010 ). Although relatively uncomplicated to administer, the CIWA-Ar does require instruction and a level of familiarity with its questions. Therefore, the NPD specialists needed instruction on how to properly perform the assessment and how to appropriately intervene. An educational slide presentation on risk assessment and the CIWA-Ar tool was reviewed with the NPD specialists by one of the advance practice nurses (APN) leading the project. Education included Nursing Grand Rounds and a No Harm Intended session. Nursing Grand Rounds is a presentation developed by nurses, and focuses on specific case studies and lessons learned. No Harm Intended sessions are presented by an interdisciplinary team for all healthcare team members, and cover actual or potential issues within the healthcare system. Providing education using an interdisciplinary approach allows a free exchange of ideas across fields, fosters an appreciation and understanding of others’ areas of expertise, and provides all those involved with an opportunity to learn from each other. Alcohol withdrawal served as a topic for both of these forums, and concentrated on situations where inpatients placed themselves or staff at high risk for injury. Nurses from inpatient units recounted difficult experiences with patients actively withdrawing from alcohol. Content experts provided information about the history of alcohol abuse management, basic pathophysiology of alcohol abuse, and current practice within our healthcare system. Key aspects of the new alcohol withdrawal CMG were introduced. The CMG included the Alcohol Withdrawal Risk Assessment (AWRA), the CIWA-Ar, order sheet, and algorithms. Completed on admission, the AWRA determines the risk for alcohol withdrawal. A score of 5 or greater prompts the nurse to complete the CIWA-Ar.

Many nurses felt the care of patients experiencing alcohol withdrawal was extremely difficult to manage and required increased nursing resources. Often times, these patients required high dosages of medication to alleviate their withdrawal symptoms, which many floor nurses were uncomfortable administering. In addition, there were several instances of patients attempting to harm themselves or harm others while withdrawing from alcohol, which contributed to nurses’ fear for patient and staff safety. Unfortunately, completing the AWRA and following the CMG were viewed as simply additional tasks for them to perform. The benefits of treating patients with alcohol withdrawal on the medical surgical units, rather than in the ICUs, were not clear to the nurses. These were some of the restraining forces that had to be addressed in order to successfully implement this new process.

INITIAL EVALUATION OF CMG IMPLEMENTATION

Documentation review.

Point prevalence assessment conducted via chart review hospital-wide one month after implementation helped to determine compliance. Nurses gathered data and were asked to determine if the AWRA was completed on admission. If the AWRA score was 5 or greater, nurses were instructed to complete a baseline CIWA-Ar. In addition, the provider was to be contacted to initiate the appropriate treatment plan and order set. In March of 2010, of the 184 charts that were reviewed, 96 (52%) had the AWRA completed. All of the patients who scored 5 or greater on the AWRA had the CIWA-Ar initiated. In April of 2010, charts for 224 patients were reviewed. Of those, 141 (63%) had the AWRA completed. Again, all of the patients who scored 5 or greater on the AWRA had the CIWA-Ar initiated. The results also showed that five patients scored 8 or greater on the CIWA-Ar; however, two of these patients did not have the CMG initiated. Moreover, these findings revealed opportunities for additional education regarding use of the AWRA and the CMG.

Focus Group

An APN involved in the alcohol withdrawal task force led a focus group to determine concerns or problems that staff nurses encountered related to implementation of the CMG. The format of the focus group included eight open-ended questions to solicit information and keep the discussion focused. Nurse managers sent staff from their units to provide representative opinions from their respective units. Two APNs with knowledge of the CMG and experience in leading focus groups facilitated, and two nurses not involved in the discussion documented the sessions.

The following themes emerged as listed in Table 1 :

• Reeducation needs,
• Effective use of CIWA-Ar scores,
• Increased burden of caring for patients on medical-surgical units,
• Limitations of the form used for documentation, and
• Ethical dilemmas.

An education subcommittee of the alcohol withdrawal team was formed in order to address knowledge gaps and assist in developing second-generation education for staff using information obtained from the focus group and other feedback. The purpose of this team was to facilitate understanding among nurses through reeducation. Units with the highest incidence of patients with the discharge diagnosis of alcohol withdrawal and/or DT were chosen to pilot this second generation of education.

PHASE II: EDUCATION FOLLOWING IMPLEMENTATION OF THE CMG

Focus group feedback, staff comments, and discussion with the interdisciplinary team revealed confusion around the correct meaning of the AWRA and CIWA-Ar scores. Furthermore, the scores were being reported to the providers interchangeably. It was clear that there was a need to remedy and clarify this misunderstanding quickly. A Safety First Alert , a rapid communication process to disseminate key safety practices and education across the organization, was used in December 2009 to provide timely communication to the appropriate staff, and focused on clarifying the difference between the two assessment tools: the AWRA score as an initial screening tool and the CIWA-Ar score as a symptom-based assessment and management tool.

According to Lewin’s Theory of Planned Change, driving forces must be identified and presented to all involved to ensure a successful transition ( Shirey, 2013 ). In this case, these forces included increased patient safety and a decrease in the incidence of DT, ICU transfers, and rapid response teams. NPD specialists were now actively involved in the alcohol withdrawal committee, and their expertise in nursing development and education was utilized to address targeted learning needs. The educators were better able to understand nursing’s various concerns and determine the focus for our educational methods in order to focus on the driving forces and bring about positive change. The goal was to educate nurses to recognize alcohol withdrawal symptoms before patients advanced to DT, and initiate treatment before the onset of severe symptoms. Therefore, education focused on increasing nurses’ depth of knowledge about the differences between Alcohol Withdrawal Syndrome versus DT. On the basis of focus group results, small group discussions occurred with the alcohol withdrawal team and staff. NPD specialists presented second-generation education using educational slides and included content in the following areas:

• physiology of alcohol withdrawal and DT;
• mechanism of action of benzodiazepines, dosing, and frequency of administration for effective management of alcohol withdrawal;
• directions on how to complete the CIWA-Ar;
• correct use of the newly implemented electronic AWRA and CIWA-Ar forms; and
• mobilization of additional resources.

This second phase of education included greater sensitivity to environmental distraction, so educators used small group instruction in break rooms.

Electronic versions of the AWRA and the CIWA-Ar forms introduced a year after initial program implementation in October 2010 now sends an electronic reminder that alerts the nurse to complete the AWRA upon admission. This transformational change reminds nurses automatically to complete the CIWA-Ar and to intervene in a timely manner.

EVALUATION OF THE CMG IMPLEMENTATION AFTER PHASE II EDUCATION

For three consecutive quarters following completion of secondary education, charts of patients with a discharge diagnosis of alcohol withdrawal or DT were reviewed as delineated in Table 2 . Increases in the percentage of AWRA completed were seen (79% in the fourth quarter of 2010, 87% in the first quarter of 2011, and 90% in the second quarter of 2011). The CIWA-Ar was administered in 94%, 100%, and 98% of patients whose charts were reviewed. One reason more patients had a greater number of CIWA-Ar completed than AWRA is that AWRA is not always completed in critical care units. Often times in these units, patients are unable to communicate verbally during the admissions process, thereby preventing an accurate assessment. Families are requested to provide the information, but are often times unable to offer a thorough history. Patients may have been admitted to these units and then later transferred to noncritical care areas.

NPD specialists knew it was important to evaluate the effectiveness of the education. The survey instrument and education plan were developed by the NPD specialists and validated by the alcohol withdrawal team. The preeducation survey consisted of four questions with Likert scale responses from 1 to 4, with 1 being none and 4 being extensive . As shown in Table 3 , one additional question was added to the posteducation survey regarding the impact of the electronic version of the CIWA-Ar.

Surveys were conducted using Zoomerang and were distributed to approximately 250 nurses on five medical units. These units were selected based on the number of patients with a discharge diagnosis of alcohol withdrawal. Preeducation surveys were conducted in October 2010, and posteducation surveys were conducted in January 2011. Responses were obtained from 88 nurses in the preeducation survey and 92 in the posteducation survey.

As shown in Figure, Supplemental Digital Content 1, https://links.lww.com/JNPD/A6 , the preeducation survey revealed that many nurses rated their knowledge of the CIWA-Ar assessment tool as moderate, substantial, or extensive. This was unexpected based on the feedback from the focus group discussion, as we expected the ratings to be much lower. The posteducation survey showed that nurses’ ratings of their knowledge of the CIWA-Ar assessment tool increased. The greatest changes occurred in the moderate, substantial, and extensive categories with a decrease in the number of nurses rating their knowledge as moderate and an increase in the number of nurses rating their knowledge as either substantial or extensive. There were improvements in ratings for all questions despite the high preeducation ratings. The second-generation education was designed to overcome the lack of knowledge needed in order to adequately care for patients at risk for or experiencing alcohol withdrawal.

Nurses were asked to rate their comfort level in caring for alcohol withdrawal patients and in using the alcohol withdrawal algorithm before and after education. Nurses rated their comfort level as none, limited, moderate, substantial, or extensive. As shown in Figure, Supplemental Digital Content 2, https://links.lww.com/JNPD/A7 statistically significant differences were found in comfort level caring for alcohol withdrawal patients, with six nurses rating their comfort limited on the presurvey and choosing that rating on the postsurvey, a decrease in nurses rating their comfort level as moderate (45 pre; 32 post) and an increase in those rating their comfort level as substantial (38 pre; 47 post). There was no change in nurses rating their comfort level as extensive (11 pre and post). Mann–Whitney U test was performed, and differences from pre to post were statistically significant ( p = .051). Comfort level with the alcohol withdrawal algorithm showed a similar pattern of change; however, this was not statistically significant, with a Mann–Whitney U test of p = .073.

Additional analysis revealed the impact of electronic assessment on the nurses’ ability to manage patients experiencing alcohol withdrawal. Figure, Supplemental Digital Content 3, https://links.lww.com/JNPD/A8 illustrates the majority (68%) of nurses rated the electronic CIWA-Ar task as having substantially or extensively improved their ability to care for this patient population. Of the remaining nurses who responded to the survey, 24% indicated moderately, 7% limited, and only 1% rated the impact as none.

Several lessons were learned from this project related to implementing change across multiple patient care units. Initially, we did not emphasize the rationale for the practice change or the physiology of alcohol withdrawal and treatment modalities. Consequently, the initial education lacked several key components and was inhibited by hastened time line for implementation. In listening to staff, the need for additional education was noted. Recognizing the value of our nurse educators in the development and planning of learning content to address behavior change, their involvement was requested. Lastly, we failed to appreciate the benefit of conducting a pilot as a means of discovering the shortcomings of our practice change.

Lewin theorized that, in order to move through the stages of change successfully, there needs to be a comprehensive action plan to engage those experiencing the transition ( Shirey, 2013 ). Unfortunately because of the pressing nature of the issues at hand, this step was overlooked in the original education plan, and therefore, the project was set up to fail. When the second generation of education was implemented, the alcohol withdrawal team and NPD specialists made great efforts to ensure that frontline staff understood the necessity and benefit of the change. By utilizing the focus groups and surveys, nurses felt their voices had been heard and were now able to unfreeze their behaviors and successfully navigate the transition. Over the past year, members of the alcohol withdrawal task force and education committee have informally rounded with bedside nurses. The conversations they have had throughout the organization support these results. These discussions revealed that they now consider themselves experts in caring for patients with alcohol withdrawal. One nurse stated, “We are seasoned nurses and we know how to take care of patients with alcohol withdrawal.” These statements indicate that nurses have “refrozen” their beliefs and new behaviors. Because of these findings and our commitment to our change model, similar education was later provided to nurses throughout the health system.

Use of the CMG has changed the course for patients admitted to the hospital at risk for alcohol withdrawal and has also increased the confidence level of nurses caring for patients at risk for alcohol withdrawal. Successful education, planning, and proper execution of the CMG by nurses and providers had direct positive impact on this patient population.

PATH FORWARD

Results of the pre- and postsurveys revealed successful reeducation efforts, and education for the remainder of the medical, surgical, and stepdown units was based on these results. A simulation involving a standardized patient experiencing alcohol withdrawal and DT was part of a collaborative learning project for resident physicians and novice nurses. Currently, an additional alcohol withdrawal simulation scenario, coupled with didactic classroom content, is incorporated into nursing orientation. Future strategies will include incorporation of alcohol withdrawal into a Web-based education module for all nurses to complete on an annual basis, and development of a video about a patient experiencing alcohol withdrawal. Through the provision of nursing education regarding alcohol withdrawal, nurses’ comfort level in caring for alcohol withdrawal patients has improved. By increasing their knowledge, nurses are more confident in caring for patients suffering from alcohol withdrawal, potentially improving multidisciplinary communication and clinical outcomes.

Supplemental Digital Content

• JNPD_36_1_2015_11_04_BERL_14-458_SDC1.pdf; [PDF] (121 KB)
• JNPD_31_6_2015_11_04_BERL_14-458_SDC2.pdf; [PDF] (63 KB)
• JNPD_31_6_2015_11_04_BERL_14-458_SDC3.pdf; [PDF] (105 KB)
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