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Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Among the domains assessed by the CIWA-Ar, tremor is the most objective indicator of withdrawal severity, however, the ability of clinicians to reliably quantify tremor is highly dependent on experience. The objective of this study was to prospectively validate an objective, reliable tool to standardize and quantify the severity of alcohol withdrawal tremor using the built-in accelerometer of an iOS application. Methods: A prospective observational study of patients ≥18 years presenting to an academic emergency department in alcohol withdrawal was conducted from Oct 2014 to Aug 2015. Assessments were videotaped by a research assistant and subsequently reviewed by 3 clinical experts, blinded to the primary clinical assessment. Tremor severity was scored using the 8-point CIWA scale (0=no tremor, 7=severe tremor). Accelerometer derived results were compared to expert assessments of each video. Inter-rater agreement was estimated using Cohen’s kappa (k) statistic. Results: 76 patients with 78 tremor recordings were included. Accelerometer derived tremor scores matched exactly with expert assessor scores in 36 (46.2%) cases, within 1 point for 73 (93.6%) cases and differed by ≥ 2 points in 5 (6.4%) cases. The overall kappa for agreement within 1 point for tremor severity was ‘very good’ 0.92 (95% CI: 0.86, 0.99). Conclusion: iOS accelerometer based assessment of the tremor component of the CIWA-Ar score is reliable and has potential to more accurately assess the severity of patients in alcohol withdrawal. We anticipate this resource will be easily disseminated and will impact and improve the care of patients with alcohol withdrawal.

Background: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom-driven approach, where patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised [CIWA-Ar]) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a curriculum to teach clinicians how to accurately assess and treat AWS.Methods: This was a three-phase education program consisting of a series of e-learning modules containing core competency material, an in-person seminar to orient learners to high-fidelity simulation, and a summative evaluation in an objective structured clinical examination setting using a standardized patient. To determine the impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the emergency department (ED) before and after training. A CIWA-Ar protocol breach was defined as inappropriate administration of benzodiazepines (CIWA-Ar < 10) and failure to administer benzodiazepines when required (CIWA-Ar ≥ 10). ED length of stay, amount of benzodiazepines administered in the ED, discharge prescriptions, and unit doses (takeaway bottle of four tablets) of benzodiazepine given were recorded.Results: Seventy-four ED nurses completed the curriculum over an 8-week period. In the 5 months prior to the educational program delivery, we identified 144 of 565 (25.5%) CIWA-Ar protocol breaches, compared to 64 of 547 (11.7%) in the 5 months after training (Δ13.8%, 95% confidence interval [CI] = 9.3%-18.3%). Program completion resulted in a reduction in the median total dose of diazepam administered in the ED (40 mg vs. 30 mg, Δ10 mg, 95% CI = 0-20 mg) and no change was detected in ED length of stay and benzodiazepines prescribed.Conclusions: Completion of this curriculum resulted in better compliance with the CIWA-Ar protocol by those who administer the CIWA-Ar; however, changes in inappropriate benzodiazepine prescribing practice will require future interdisciplinary initiatives.